By recei - If the authorization number is missing from Box# 23 on the physician billing or CMS1500 form or Locator# 63 on the hospital billing or the UB04 form,.
- Coverage limitations: The coverage limitations were in the patient’s insurance plan, but the service was provided.
- The procedure was experimental or investigational: If healthcare providers choose any innovative treatments that are not commonly known or medically necessary but still performed, it may lead to CO 197 denials. The necessary documentation, such as medical records or test results, should be provided to the insurance company before performing any treatment or procedure.
- There were coding or billing errors: Always ensure that the correct diagnosis and procedure codes are used as per the latest coding changes.
- Insurance guidelines: Provider must adhere to the specific guidelines or criteria set up by insurance companies as If these guidelines are not followed, it may trigger code 197 denial.
- Missing pre-treatment documentation: Code 197 may also be triggered if the necessary documentation, such as medical records or test results, is not provided to the insurance company before the treatment or procedure. Insurance companies often require this documentation to determine the medical necessity of the service.
Follow-up:
- Authorization is not available. If the authorization number is not available in the system, always ask for the retro authorization number and follow up accordingly.
- Retro Authorization: A healthcare provider can request approval from an insurance company for a medical service that has already been performed on a patient.
- Emergency service: If the service is an emergency service, then it can always be challenged, as certification is not required in this case. The codes 99281-99285 are used for reporting evaluation and management services in the emergency department.
- Stay Updated: Always communicate with insurance to stay updated on their specific pre-authorization requirements. By monitoring and analyzing denial patterns, common causes can be resolved, and it can prevent future denials. Educate staff on pre-authorization requirements
- Authorization: The authorization# for the specific CPT code remains valid under the specific time period, so always look for this duration.
- Submit an appeal or corrected claim: Prepare an appeal or corrected claim that includes the missing documentation. Clearly explain the reason for the initial denial and provide a detailed explanation of how the missing documentation has been addressed. Follow the insurance company’s guidelines for submitting appeals or corrected claims, including any specific forms or procedures.
Conclusion
The CO 197 denial code is a very common denial given by insurance companies, and by taking some steps, healthcare providers can minimize this to avoid any financial and operational impact.
Also read: Underpayment