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.
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.
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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.
| Attribute | Value | Technical Guidance |
|---|---|---|
| Reason Code | CARC 197 | Precertification / Prior Authorization Absent |
| Standard Group Code | CO | Contractual Obligation |
| ANSI 835 Segment | CAS*CO*197*AMOUNT~ | Loop 2110 or Loop 2100 |
| Balance Billing Patient | Prohibited for in-network providers in most commercial and Medicare Advantage contracts. | Compliance with billing regulations |
| Common RARCs | N54, N704 | Remittance Advice Remark Codes |
| Recommended Action | 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. | Workflow for billing teams |
Parsed JSON Response Model
The edge microservice transforms input payloads into strongly-typed hierarchical JSON envelopes with sub-5ms latency:
{
"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
}
]
}
}
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Frequently Asked Questions & Technical Notes
CARC 197 signifies: "Precertification/authorization/notification/prior determination absent, or exceeded.". It explains why the payer did not pay the full billed charge.
Prohibited for in-network providers in most commercial and Medicare Advantage contracts.
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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