Denial codes · Denial code
CO-197 on a nutrition claim: the authorization was missing
By Javier Alvarez · Updated · 3 min read
| Official description | Precertification/authorization/notification/pre-treatment absent. |
|---|---|
| Group code | CO: in network, not billable to the patient |
| Common remark codes | M62 (authorization code), N54 (inconsistent with authorized services) |
| Where the auth number goes | CMS-1500 Item 23 (prior authorization number) |
| Who tends to require it | Some Medicaid managed care, HMO and commercial plans; varies by plan |
| Fix route | Corrected claim if the auth existed; retro-auth or appeal if not |
Most dietitians rarely deal with prior authorization, which is exactly why CO-197 stings: the one plan that required it is the one nobody asked about. Sometimes the authorization existed and simply did not make it onto the claim. Sometimes it never existed. The fix is different for each.
What CO-197 means
The X12 CARC list defines code 197 as:
"Precertification/authorization/notification/pre-treatment absent."
That covers several flavors of the same rule: a formal prior authorization, a precertification, a notification the plan wants before or at the start of care, or a pre-treatment plan. Look for these remark codes next to it (X12 descriptions):
- M62: "Missing/incomplete/invalid treatment authorization code." The auth may exist but was not on the claim, or was mistyped.
- N54: "Claim information is inconsistent with pre-certified/authorized services." An auth exists, but the claim does not match it: different code, more units or visits, dates outside the approved range, or a different provider.
The CO group code means the provider is liable.
Which plans require authorization for nutrition
There is no universal rule, and it changes. Patterns we see:
- Medicaid managed care plans sometimes require authorization for nutrition counseling, or for visits beyond an initial number.
- HMO and some commercial plans may require a referral on file from the primary care physician, sometimes plus an authorization. Referral and authorization are different things; a plan can require one, both, or neither.
- Medicare Advantage plans set their own rules; some require an authorization or referral on file for MNT. See Medicare Advantage billing for dietitians.
- Original Medicare requires a treating physician's referral for MNT (NCD 180.1), not a prior authorization. A missing referral on a Medicare claim usually comes back as CO-16 with a referring-provider remark code.
- Visit-count triggers: some plans allow a set number of visits without authorization and require one after that. Visit 7 can deny when visits 1 to 6 paid.
The only reliable answer comes from the member's plan: the provider manual's authorization list and the benefits call. Our prior authorization guide for nutrition services covers how to request one.
How to fix a CO-197
If an authorization existed
- Find it: the auth number, approved codes, number of visits or units, date range and approved provider.
- Compare with the claim. Was the number in Item 23 of the CMS-1500? Did the code, units, dates and rendering provider match what was approved?
- Send a corrected claim (frequency code 7 with the original claim number) with the auth number in Item 23 and the claim matching the approval. If the auth covered fewer visits or units than you provided, request an extension or update from the payer first.
If no authorization existed
- Ask about retro-authorization. Some payers accept a retroactive request within a set window after the visit; others do not. The provider manual says which. Submit it with the note and the referral.
- Appeal if you were misinformed. If your benefits call said no authorization was needed, appeal with the call date, the representative's name and the reference number. That is the strongest argument you have. See how to appeal a denied nutrition claim.
- Get authorization for future visits now, before the next session, so the damage stops at one claim.
Can you bill the patient?
In network, generally no. Obtaining authorization is typically the provider's responsibility under the contract, and CO-197 assigns the loss to the provider. There are narrow exceptions in some contracts (for example, when the patient withheld insurance information), so read yours before billing anyone. Out of network, it depends on your agreement with the patient.
How to prevent CO-197
- Ask three questions on every benefits check: Is a referral required? Is an authorization or notification required, and after how many visits? How do I submit it? Our verification call script includes the wording.
- Record the answer with the date, representative and reference number. It is your appeal evidence later.
- Track authorized visits and dates per patient, and request an extension before the last approved visit.
- Put the auth number on every claim it covers, in Item 23.
- Re-check at plan renewal and whenever the patient changes plans.
For every other nutrition denial code, see the denial code lookup.