PR-197: Precertification/Authorization/Notification Absent
The patient's plan required a referral that was not obtained. The patient owes the charges. Help the patient get a retroactive referral if the payer allows it — otherwise, bill the patient directly.
What Does PR-197 Mean?
PR-197 is less common and typically appears when the patient's plan (often an HMO) required the patient to obtain a referral from their primary care physician before seeing a specialist, and the referral was not obtained. The financial responsibility falls on the patient because the authorization requirement was part of the patient's plan obligations, not the provider's contractual duty.
CARC 197 is one of the most common and costly authorization-related denials in medical billing. It fires when the payer determines that a required precertification, prior authorization, notification, or pre-treatment step was absent at the time the service was delivered. The claim is denied not because the service was clinically inappropriate, but because the administrative prerequisite was not completed.
The most frequent scenario is straightforward: the provider rendered a service that requires prior authorization under the payer's policy, and no authorization was obtained. But CARC 197 also fires in more subtle situations — an authorization was obtained but the authorization number was left off the claim, the dates of service fall outside the authorization window, the CPT codes billed do not match the approved procedure, or the units delivered exceed what was authorized. In each case, the payer's system sees no valid authorization attached to the claim.
Under CO (the dominant group code), the provider absorbs the denial because the contractual obligation to obtain authorization fell on the practice. The provider cannot bill the patient for the denied amount. Under PR, which is less common, the patient was responsible for obtaining a referral under their plan (e.g., HMO requiring PCP referral to specialist) and failed to do so. The financial impact of CARC 197 denials is significant — these are often fully denied claims, not partial adjustments — making prevention through robust authorization workflows critical.
Common Causes
| Cause | Frequency |
|---|---|
| Patient failed to obtain required referral The patient's plan requires a referral from the primary care physician before seeing a specialist, and the patient did not obtain this referral before receiving services | Most Common |
| Patient chose out-of-network provider requiring separate authorization The patient elected to receive services from a provider that requires separate authorization under their plan, and the authorization was not obtained | Common |
How to Resolve
Search for an existing authorization, request reprocessing or retroactive auth, and appeal if necessary.
- Verify the referral requirement Confirm with the payer that the patient's specific plan requires a PCP referral for the service rendered and that no referral is on file.
- Assist with retroactive referral Contact the patient and their PCP to request a retroactive referral if the payer's policy allows it. Resubmit the claim with the referral number once obtained.
- Bill the patient if no retroactive referral is possible If the payer does not accept retro referrals, transfer the balance to the patient's account with a clear explanation of why the referral was required and not obtained.
- Offer payment options Provide the patient with payment plan options if the balance is substantial, and document the patient communication for your records.
This adjustment is correct per the patient's benefit plan. The amount is the patient's financial responsibility. Collect from the patient rather than appealing.
How to Prevent PR-197
- Verify at scheduling and check-in whether the patient's plan requires a referral and confirm the referral is on file before the appointment
- Implement a referral verification check in your intake workflow that blocks the appointment from proceeding without a confirmed referral
- Educate patients about their plan's referral requirements during registration and in pre-visit communications
General Prevention
- Inform patients at scheduling whether their plan requires a referral and verify it has been obtained before the appointment
- Implement a referral verification check at patient check-in to catch missing referrals before services are rendered
Also Filed As
The same CARC 197 may appear with different Group Codes: