Denial code · CARC 197
CARC 197 (CO-197): no authorization on file for a behavioral-health service
What CO-197 means, why it hits admissions, IOP, PHP, testing and ABA, which remark codes explain it, and when a corrected claim fixes it instead of an appeal.
By the ClaimParrot editorial team · Who we are · Reviewed · 5 min read · 7 cited sources
Quick answer
CARC 197 means the payer required precertification, authorization or notification for the service and found none on file for this claim. In behavioral health it most often hits admissions, IOP, PHP, psychological testing and ABA. First look for an approval under another number, provider, code or date; if one exists, a corrected claim or reconsideration usually fixes it.
| Item | Detail |
|---|---|
| Code | CARC 197 · Active on the X12 list; checked October 14, 2026 |
| Plain meaning | The plan required precertification, authorization or notification before this service, and it found none it could match to the claim. |
| Group codes seen | CO (contractual obligation), PR (patient responsibility) |
| Common remark codes | M62, N54, N385, N758 |
| Where it shows up in BH | Inpatient psychiatry, Residential SUD (ASAM levels), Intensive outpatient (IOP), Withdrawal management (detox), ABA therapy, Outpatient therapy |
| Usual next step | Find the approval: corrected claim if it exists, appeal if it does not |
| Related codes | CARC 198, CARC 39, CARC 15, CARC 16 |
What does CARC 197 mean?
CARC 197 says the plan's rules called for approval or notice before the service and the payer could not match one to the claim. It does not say the care was unnecessary. The questions are procedural: was approval required on that date, did it exist, and does the claim point to it correctly?
X12 last revised 197 and its sibling CARC 198 in May 2018, when it also retired CARC 15. Today an authorization problem can arrive as 197 (nothing on file), 198 (approval exceeded) or CARC 16 with remark code M62 (number missing or invalid).
What do CO-197 and PR-197 mean for who pays?
CO-197 is the usual form: the contract makes getting approval the provider's job, so the provider carries the line until an approval is matched or the denial is overturned. PR-197 means the plan puts the missing approval on the member, for example where the plan makes members responsible for approvals with out-of-network providers.
| Group + reason | What it signals | Who usually carries the balance |
|---|---|---|
| CO-197 | Provider did not obtain or link the required approval | Provider; do not bill the patient |
| PR-197 | Plan treats the approval as the member's duty | Patient, under the plan terms and any agreement with them |
Which remark codes come with CARC 197?
The remark code usually tells you whether nothing was found or the claim did not match what was found.
| Remark code | What it adds | What to check |
|---|---|---|
| M62 | The treatment authorization number is missing, incomplete or not valid. | The authorization number field on the claim, character by character |
| N54 | Details on the claim do not match what was pre-certified or authorized. | Provider, NPI, codes and dates on the approval versus the claim |
| N385 | The admission was not reported to the plan within the time its procedures require. | When and how the admission was reported, with proof of the time |
| N758 | The payment was adjusted to match the prior-authorization decision. | The approval letter: what was approved, partially approved or denied |
Where does CARC 197 show up in behavioral health?
Behavioral-health 197 denials concentrate at admissions and at the start of new service lines. Common causes are a notice sent to the medical plan instead of the behavioral-health carve-out, an approval issued under a different NPI or level-of-care code, and services started before the approval date.
| Care setting | Typical trigger | Check first |
|---|---|---|
| Inpatient psychiatry | Admission notice sent late or to the wrong entity | Admission time stamp and proof of notification |
| Residential SUD (ASAM levels) | Approval issued to a different facility NPI or level | Approval letter: NPI, level of care, start date |
| Intensive outpatient (IOP) | Approval for one IOP code, claim billed under another | Codes on the approval versus the claim |
| Withdrawal management (detox) | After-hours urgent admission with no same-day notice | The plan's urgent-admission notice rule |
| ABA therapy | Assessment approved, treatment codes not yet approved | Approved codes and date range per code |
| Outpatient therapy | Psychological testing hours begun before approval | Approval date versus each date of service |
Corrected claim, reconsideration or appeal: which fits CARC 197?
Find the approval before writing anything. If one exists but the claim missed it or named the wrong provider or code, send a corrected claim or a reconsideration with the approval attached. If none exists, ask whether the plan accepts retroactive authorization for urgent admissions; otherwise appeal under the plan's own rules.
- 01Search the payer portal and your UR log by member, date range and every NPI that could have requested the approval.
- 02Matching approval found: correct the claim (number, rendering or billing NPI, code) and resubmit, or request a reconsideration with the approval attached.
- 03No approval: check the plan's retro-authorization and urgent-admission rules, then appeal with proof of notice attempts and the clinical urgency.
What evidence resolves a CARC 197?
For CO-197 the decisive evidence is administrative: the approval itself, or proof that you tried to get one in time. Clinical records matter mainly when you argue urgency or that the service was not on the plan's prior-authorization list for that date.
- Approval letter or portal screenshot with the reference number
- Call reference numbers, dates and names from the UR log
- Fax confirmations or portal time stamps showing when notice was sent
- The plan's prior-authorization list in effect on the date of service
- Admission records showing urgency for after-hours admissions
How do Medicare, Medicaid and commercial plans differ on CARC 197?
Who requires approval, and how fast the plan must decide, depends on the program. Since January 1, 2026, Medicare Advantage, Medicaid and CHIP plans must decide standard prior-authorization requests within 7 calendar days and urgent ones within 72 hours, and give a specific reason when they deny.
| Program | What differs |
|---|---|
| Medicare Advantage | Plans can require approval for behavioral-health services. CMS-0057-F decision clocks apply; a reconsideration is due within 60 days of the decision. |
| Medicaid | Each state and MCO keeps its own list. Ohio Medicaid, for example, requires approval for SUD partial hospitalization (H0015 with TG). |
| Commercial and ERISA plans | The plan document defines pre-service claims: urgent decisions within 72 hours, standard within 15 days. |
CO-197 on a residential admission
A fictional residential SUD program admitted a patient late on a Friday and called the member's medical plan, which said it had no record of the request. The claim came back CO-197 with N385.
The program's UR log showed the call, but the plan's behavioral health was managed by a separate company that never received notice. The team asked the carve-out for its urgent-admission rule, sent the admission time stamp, the call record and the withdrawal scores, and requested a retroactive review.
Names, dates, payers and amounts are invented for illustration.
What a ClaimParrot packet does here
- When CARC 197 needs an appeal rather than a corrected claim, an appeal packet answers the payer's stated reason.
- A person checks every packet: $29, or $99 for level of care, and the first is free (pricing).
- No remittances, records or PHI are sent: just the reason and a de-identified summary (Trust & security).
Every draft is reviewed and approved by your team. ClaimParrot does not make medical-necessity determinations or give legal advice.
Frequently asked questions
Does CO-197 mean the care was not necessary?
No. CARC 197 is about a missing approval or notice, not clinical need. A medical-necessity denial would normally use CARC 50.
What is the difference between CARC 197 and CARC 198?
197 means no approval was found for the service. 198 means an approval exists but the claim goes beyond it: more units or days, or dates outside the approved window.
Can a retroactive authorization fix a CO-197?
Sometimes. Many plans allow retroactive requests in set situations such as urgent admissions or retroactive eligibility, but rules and windows differ by plan, so check the provider manual before relying on it.
We had a phone approval. Why did the claim still deny with 197?
Verbal approvals often fail to reach the claim system or are recorded under another provider or code. Send the call reference number, date and representative name, and ask the payer to link the approval and reprocess.
Primary sources and references
- Claim Adjustment Reason Codes (CARC) code list · X12 · checked
- Remittance Advice Remark Codes (RARC) code list · X12 · checked
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet · CMS · checked
- 29 CFR 2560.503-1: ERISA claims procedure · eCFR · checked
- 42 CFR 422.582: requesting a Medicare Advantage standard reconsideration · eCFR · checked
- Ohio Medicaid Behavioral Health Provider Requirements and Reimbursement Manual, v1.28.1 (March 2026) · Ohio Department of Medicaid · checked
- Aetna provider disputes and appeals overview · Aetna · checked
General information, not legal or medical advice. Payer rules change; confirm deadlines and requirements in the notice and the plan documents. Read our editorial policy.
Decode the next line on the remittance.
Type a group and reason code such as CO-197 or PR-96, or a remark code such as N386. The lookup runs in your browser and needs no patient details.