What does CARC 197 mean?

CARC 197 means 'Precertification, authorization, notification or pre-treatment absent.' The payer denied the claim because prior authorization was required and was not obtained before the service.

Can I get retroactive prior authorization?

Often yes, within a payer-specific window (commonly 7-30 days post-service) and especially for emergency services or retroactively eligible patients. Call the payer's auth line and request it.

How do I prevent prior auth denials?

Build a prior auth check into scheduling. Verify whether the scheduled service requires auth with the patient's specific plan, and don't render the service until auth is on file, or have the patient sign an ABN acknowledging financial responsibility.

How to Appeal a Prior Authorization Denial (CARC 197)

CARC 197, Prior Authorization

"Precertification/authorization/notification/pre-treatment absent.". Appealable: Yes, in specific circumstances

Prior authorization denials are process failures, either the authorization wasn't obtained, it was obtained for the wrong service or date range, or it wasn't referenced correctly on the claim. The good news: many CARC 197 denials are recoverable once you understand exactly which scenario you're dealing with.

Determine Which Scenario You're In

Before doing anything else, confirm what actually happened:

Scenario A: Auth was obtained but not submitted on the claim. This is purely administrative, the auth existed but the auth number wasn't on the claim. Corrected claim resubmission with the auth number typically resolves it.
Scenario B: Auth was obtained for the wrong date or service code. The auth references a different date of service or a different procedure. This may require a retroactive auth request or a corrected claim if the service falls within the auth window.
Scenario C: Auth was never obtained. The service was rendered without authorization. This is the hardest scenario, but retroactive authorization is sometimes available for urgent/emergent situations.
Scenario D: Auth was obtained but payer lost or misapplied it. Payer processing error, appeal with the auth number, date obtained, and the name of the representative who issued it if you have it.

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