Decoding Denials: Learn About CO-197

Decoding Denials for Healthcare RCM Teams

One of the most important aspects of an RCM team’s job is understanding unique denial codes. Denial codes offer critical information as to why claims are getting rejected. Each unique code represents a different reason for a denial and can offer a path to quickly recovering the revenue you deserve. 

Being able to quickly understand and act on denial codes empowers your team to uncover operational inefficiencies, secure revenue, and implement strategic methods to prevent or respond to unique codes. 

In this blog, we’re going to decode the denial code CO-197 so that your team can be prepared to address it in the future. Let’s get into it!

What is Denial Code CO-197

Definition: Denial Code CO-197 means that the precertification, prior authorization, notification, or pre-treatment requirement was not fulfilled ahead of services being rendered.

Common Cause of Denial Code CO-197

Cause: Denial Code CO-197 can occur as a result of multiple different mishaps. These can include:

• Prior authorization is not obtained or not obtained in proper timeframe
• Failure to notify the insurance company ahead of procedure
• Missing pre-treatment documentation
• Inadequate supporting documentation
• Failure to obtain a second opinion if required
• The patient fails to meet certain medical criteria

Example: Let’s look at a real-life example. A patient, we can call him Tom, visits a primary care physician for back pain. His doctor recommends that he gets an MRI to investigate the potential cause of the pain. Before Tom schedules the appointment for an MRI, his primary care doctor submits a request to Tom’s insurance company for authorization to proceed with the scan. The authorization request typically includes details like Tom’s medical history, symptoms, the physician's assessment, and the necessity of the procedure. Once the insurance team reviews the request and approves it, Tom can schedule his MRI. If Tom schedules his MRI and receives the scan before his insurance company approves the request, the claim will most likely be met with a CO-197 denial code.

Responsibility: In this case, the portion of the code that says “CO” refers to the fact that it is a result of a contractual obligation. This means that the provider team needs to investigate the claim to understand why the claim does not align with the contract between themselves and the payer. 

Ways to Mitigate Denial Code CO-197

Prevention: Denial Code CO-197 can easily be avoided by taking precautions to ensure proper certification, notification, documentation, and medical necessity requirements are all met ahead of services being rendered.

• Bolster or even automate your prior-authorization process
• Streamline communication with payers
• Ensure your team is well-versed on prior authorization requirements
• Improve documentation processes 
• Monitor and track denials for trends and patterns
• Establish a process for efficient responses to trends

How to Address Denial Code CO-197

Response: If you receive Denial Code CO-197, there are a few steps you can take to uncover and address the root of the problem. 

1. Review the patient’s medical records to ensure that prior-authorization, notification, documentation, and medical necessity needs are being met. Identify any gaps.
2. Identify if there is a reason for the gap.
3. Contact the insurance company to understand the specific requirements for the claim and clear up any ambiguity so you don’t run into the same issue in the future.
4. Obtain missing documentation such as medical records, signatures, etc. 
5. Submit your appeal or corrected claim.
6. Track the progress of your appeal or corrected claim to ensure the appropriate documentation is accepted.

How Adonis Can Help

Obtaining prior authorization for services is a critical step in ensuring accurate and timely revenue outcomes. Adonis’s prior authorization automation improves patient access to care, reduces downstream claim denials, and minimizes FTE resources and spend on manual, repetitive tasks. With Adonis’ revenue cycle management automations for prior authorization, teams can avoid Denial Code CO-197.