CARC 197
Precertification / Auth Absent
Authorization not obtained prior to service. Tagged auth_missing, high priority.
→ PA appeal workflow; submit retro-auth request
Understand claim adjustment reason codes (CARC), EOB denial codes, and the most common denial codes in healthcare. Our agent maps the medical billing denial codes list, automating routing to the right resolution action.
Most revenue loss comes from a handful of preventable issues — clinical documentation, prior authorization, and eligibility gaps — long before claims are even submitted.
Authorization not obtained prior to service. Tagged auth_missing, high priority.
Service not covered under patient plan. Contract review before appeal decision.
Claim missing required information. Auto-populate from EHR and rebill within 24h.
Incorrect modifier or procedure code. Route to coding queue with suggested fix.
Claim past payer filing deadline. Gather clearinghouse proof of timely submission.
Claim already adjudicated. Verify original disposition before action taken.
Patient not covered on date of service. Re-verify and identify correct payer.
Auth expired, missing, or mismatched. Check PA agent log for submission record.
COB issue — claim submitted to incorrect primary payer in sequence.
Decision based on specific Local Coverage Determination. Must cite exact LCD criteria.
Supplemental to CARC 197. High-value claims escalated to peer-to-peer track.
Charges not covered — verify benefit structure and patient responsibility split.
See how Agent 03 parses 835 EDI data, interprets denial codes, and maps them to the right action — automatically.
CLP*CLAIM12345*4*1500*0*0*MC*REF123~ CAS*CO*197*1500~ CAS*CO*16*0~ SVC*HC:99214*1500*0*1~ LQ*HE*N657~
CLP*…*4 Claim status 4 = DeniedCAS*CO*197*1500 Contractual Obligation · CARC 197 = Precertification absent · $1,500 adjustmentLQ*HE*N657 RARC N657 = “Authorization was not obtained prior to service”See Agent 03 work through your actual denial data in a live demo.
Book Free DemoDenial codes in medical billing are standardized codes used by payers to explain why a claim was denied or adjusted. These include claim adjustment reason codes (CARC) and EOB denial codes, helping providers identify issues and take corrective action quickly.
The most common denial codes in healthcare include CO-45 (charge exceeds fee schedule), CO-97 (included in another service), and CO-252 (authorization missing). Understanding these common denial codes in healthcare helps providers reduce errors and improve claim acceptance rates.
CO-45 denial code means the billed charge exceeds the payer’s allowed amount based on their fee schedule. This is one of the most frequent denial codes in medical billing, and typically results in a contractual adjustment rather than an appeal.
CO-97 denial code on an EOB indicates that the billed service is included in another procedure already paid. This EOB denial code is often related to bundling rules and requires proper coding review to avoid repeated denials.
CO-252 denial code means prior authorization was required but not obtained before the service was provided. This is a common claim adjustment reason code and can often be resolved through retro-authorization or appeal with proper documentation.
Denial codes are used in claims processing to communicate why a claim was rejected or adjusted. Denial codes in medical billing help providers identify root causes, correct errors, and resubmit or appeal claims efficiently within the revenue cycle.
CARC (Claim Adjustment Reason Codes) explain the financial reason for a denial, while RARC (Remittance Advice Remark Codes) provide additional context. Together, these claim adjustment reason codes and remarks help providers fully understand denial causes and take appropriate action.
Providers can resolve denial codes quickly by identifying root causes, correcting claim errors, and submitting appeals with proper documentation. Using medical billing denial codes lists and automation tools helps streamline resolution and reduce turnaround time.
Insurance companies use denial codes to standardize communication about claim decisions. These EOB denial codes and CARC codes ensure providers understand why a claim was denied and what actions are needed to correct or appeal it.
Denial codes can be prevented by verifying eligibility, obtaining prior authorizations, ensuring accurate coding, and submitting complete documentation. Addressing these common issues helps reduce denial codes in medical billing and improves clean claim rates.
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