CARC 197Authorization Appealable

Precertification/authorization/notification/pre-treatment absent

Q: Is CARC 197 appealable?

Yes, CARC 197 is appealable with an estimated win rate of approximately 80.00%.

Quick Action: Check auth status; if obtained, resubmit with auth number. If missed, request retro-auth.

Typically seen with:CO — Contractual ObligationOA — Other Adjustment

~80.00%

Estimated appeal win rate for CARC 197 denials

What Does CARC 197 Mean?

CARC 197 — "Precertification/authorization/notification/pre-treatment absent" — is a Claim Adjustment Reason Code used by payers to indicate why a claim or service line was adjusted. This code falls under the Authorization category.

Common Causes

Here are the most common reasons this denial code appears on your remittance advice:

Prior authorization was required but not obtained before the service
Authorization number not included on the claim
Authorization expired before the date of service
Authorization was for a different procedure or quantity than what was billed
Retrospective authorization request was denied or not submitted

Is CARC 197 Appealable?

Yes, CARC 197 is appealable. With proper documentation and a well-crafted appeal, this denial code has an estimated win rate of approximately 80.00%. This is one of the higher-success-rate denial codes — prioritize these appeals.

How to Appeal CARC 197

Follow these steps to maximize your chances of a successful appeal:

1 If authorization was obtained, resubmit with the correct auth number

2 If authorization was missed, request a retrospective authorization from the payer

3 Gather clinical documentation showing the service was medically necessary and urgent

4 Check if the payer allows exceptions for emergency or urgent services

5 File a formal appeal citing the clinical urgency and medical necessity

Related RARC Codes

These Remittance Advice Remark Codes are commonly paired with CARC 197. The RARC tells you the specific reason for the adjustment.

MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable

N362 The number of Days or Units of Service exceeds our acceptable maximum

N386 This decision was based on a National Coverage Determination (NCD)

Appeal Letter Template

.DOCX

Customize the fields below to generate a ready-to-send appeal letter for CARC 197. Downloads as a formatted Word document.

Practice/Organization

Payer Name

Claim Number

Patient Name

Member ID

Date of Service

Denied Amount

Provider Name

NPI

Phone

Letter Body (editable)

[Date]
[Payer Name]
[Payer Address]

RE: Appeal for Claim #[Claim Number]
Patient: [Patient Name] | Member ID: [Member ID]
Date of Service: [Date of Service] | Denied Amount: $[Denied Amount]

Dear Claims Review Department,

I am writing to formally appeal the denial of the above-referenced claim, denied with CARC 197: "Precertification/authorization/notification/pre-treatment absent".

Our appeal is based on the following:

- If authorization was obtained, resubmit with the correct auth number
- If authorization was missed, request a retrospective authorization from the payer
- Gather clinical documentation showing the service was medically necessary and urgent
- Check if the payer allows exceptions for emergency or urgent services
- File a formal appeal citing the clinical urgency and medical necessity

We have reviewed the common reasons for this denial and can confirm that the following do not apply to this claim:

- Prior authorization was required but not obtained before the service
- Authorization number not included on the claim
- Authorization expired before the date of service
- Authorization was for a different procedure or quantity than what was billed
- Retrospective authorization request was denied or not submitted

Recommended action: Check auth status; if obtained, resubmit with auth number. If missed, request retro-auth.

Enclosed please find supporting documentation for your review. We respectfully request reconsideration and payment of $[Denied Amount].

Sincerely,
[Provider Name]
[NPI] | [Phone]
[Practice/Organization Name]

Letter Preview

This is how your letter will look when downloaded

March 26, 2026

[Payer Name]

[Payer Address]

RE: Appeal for Claim #[Claim Number]

Patient: [Patient Name] | Member ID: [Member ID]

Date of Service: [Date of Service] | Denied Amount: $[Denied Amount]

Dear Claims Review Department,

I am writing to formally appeal the denial of the above-referenced claim, denied with CARC 197: "Precertification/authorization/notification/pre-treatment absent".

Our appeal is based on the following:

If authorization was obtained, resubmit with the correct auth number
If authorization was missed, request a retrospective authorization from the payer
Gather clinical documentation showing the service was medically necessary and urgent
Check if the payer allows exceptions for emergency or urgent services
File a formal appeal citing the clinical urgency and medical necessity

We have reviewed the common reasons for this denial and can confirm that the following do not apply to this claim:

Prior authorization was required but not obtained before the service
Authorization number not included on the claim
Authorization expired before the date of service
Authorization was for a different procedure or quantity than what was billed
Retrospective authorization request was denied or not submitted

Recommended action: Check auth status; if obtained, resubmit with auth number. If missed, request retro-auth.

Enclosed please find supporting documentation for your review. We respectfully request reconsideration and payment of $[Denied Amount].

Sincerely,

[Provider Name]

[NPI] | [Phone]

[Practice/Organization Name]

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