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CARC 197 Denial Code (Precertification / Prior Authorization Absent) | ANSI 835 EDI Spec

Comprehensive healthcare EDI technical reference and denial resolution guide for Claim Adjustment Reason Code 197 (Precertification / Prior Authorization Absent) under ANSI ASC X12 835 005010X221A1.

Official Regulatory Standard & Verification Protocol Authority: Accredited Standards Committee X12 / HIPAA 5010 ↗

Direct Answer Capsule: Comprehensive healthcare EDI technical reference and denial resolution guide for Claim Adjustment Reason Code 197 (Precertification / Prior Authorization Absent) under ANSI ASC X12 835 005010X221A1. Conforms strictly to ANSI ASC X12 Standards (005010) with zero cold-starts and deterministic edge verification.

Execution SLA
<2ms Edge (Cloudflare V8)
Governing Norm
ANSI 835 / WPC CARC
Active Standard
Throughput Limit
512 KB / Payload
Data Privacy
100% In-Memory (Zero Store)
Interactive Edge Workbench

⚡ Live CARC 197 Denial Code (Precertification / Prior Authorization Absent) | ANSI 835 EDI Spec Interactive Workbench

Test real-time validation and deterministic schema parsing for CARC 197 Denial Code (Precertification / Prior Authorization Absent) | ANSI 835 EDI Spec directly in your browser. Sub-5ms Cloudflare edge execution with zero setup.

32KB Demo Cap 60 req/min Burst <2ms V8 Compute Zero Data Retention
input.x12 0 B
output.json demo-ready
Status: Ready
{
  "status": "Click 'Run Edge Parse' to test live on Global Edge Isolates..."
}
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Specification & Structural Breakdown

Technical Rule Summary: Implementation conforms strictly to ANSI ASC X12 Standards (005010). Data ingestion is fully deterministic: identical inputs always produce bit-for-bit identical outputs without ambient side-effects.

Claim Adjustment Reason Code (CARC) 197 communicates: "Precertification/authorization/notification/prior determination absent, or exceeded.".

In ANSI X12 835 Electronic Remittance Advice (ERA) files, CARC 197 is reported in Loop 2110 (Service Payment Information) or Loop 2100 (Claim Payment Information) under the Claim Adjustment (CAS) segment with Group Code 'CO' (Contractual Obligation), formatted as: CAS*CO*197*AMOUNT~.

Root Cause: Procedure required mandatory payer prior authorization (PA) that was either not obtained before service or not included in Loop 2300 REF*G1 on the 837 claim.

Adjudication & Appeal Strategy: Verify if PA was approved prior to treatment and resubmit claim with PA number in REF*G1. If not obtained, file retroactive authorization appeal if permitted by payer policy.

AttributeValueTechnical Guidance
Reason CodeCARC 197Precertification / Prior Authorization Absent
Standard Group CodeCOContractual Obligation
ANSI 835 SegmentCAS*CO*197*AMOUNT~Loop 2110 or Loop 2100
Balance Billing PatientProhibited for in-network providers in most commercial and Medicare Advantage contracts.Compliance with billing regulations
Common RARCsN54, N704Remittance Advice Remark Codes
Recommended ActionVerify if PA was approved prior to treatment and resubmit claim with PA number in REF*G1. If not obtained, file retroactive authorization appeal if permitted by payer policy.Workflow for billing teams

Parsed JSON Response Model

The edge microservice transforms input payloads into strongly-typed hierarchical JSON envelopes with sub-5ms latency:

HTTP 200 JSON Response Envelope
{
  "transactionType": "835",
  "claimNumber": "CLM-2026-001",
  "adjudication": {
    "billedAmount": 500,
    "paidAmount": 0,
    "adjustments": [
      {
        "groupCode": "CO",
        "groupName": "Contractual Obligation",
        "reasonCode": "197",
        "reasonDescription": "Precertification / Prior Authorization Absent",
        "adjustmentAmount": 500
      }
    ]
  }
}

Copy-Paste Integration Code (5 Languages)

Integrate CARC 197 Denial Code (Precertification / Prior Authorization Absent) | ANSI 835 EDI Spec directly into your production application with native, zero-dependency code snippets in cURL, Node.js, Python, Go, and C#:

curl --request POST \
  --url "https://healthcare-edi-ansi-x12-parser-837p-835-271.stanzaapi.com/api/v1/x12/parse" \
  --header "Content-Type: application/json" \
  --header "x-api-key: YOUR_API_KEY" \
  --data '{
  "raw": "ISA*00*          *00*          *ZZ*SUBMITTER1     *ZZ*RECEIVER01     *260830*1200*^*00501*000000001*0*P*:~GS*HC*SENDER*RECEIVER*20260830*1200*1*X*005010X222A1~ST*837*0001*005010X222A1~BHT*0019*00*CLAIM001*20260830*1200*CH~NM1*41*2*DR DOE CLINIC*****46*1234567890~PER*IC*SUPPORT*TE*8005551212~HL*1**20*1~NM1*85*2*DR DOE CLINIC*****XX*1992837465~HL*2*1*22*0~NM1*IL*1*SMITH*JANE****MI*W123456780~CLM*CLM001*150.00***11::1*Y*A*Y*Y~LX*1~SV1*HC:99213*150.00*UN*1***1~SE*11*0001~GE*1*1~IEA*1*000000001~"
}'

Frequently Asked Questions & Technical Notes

What does CARC 197 mean on an 835 ERA?

CARC 197 signifies: "Precertification/authorization/notification/prior determination absent, or exceeded.". It explains why the payer did not pay the full billed charge.

Can a provider balance-bill the patient for CARC 197?

Prohibited for in-network providers in most commercial and Medicare Advantage contracts.

How do medical billing teams resolve and appeal CARC 197?

Verify if PA was approved prior to treatment and resubmit claim with PA number in REF*G1. If not obtained, file retroactive authorization appeal if permitted by payer policy.

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