CO-197 on a dental claim: missing preauthorization, and whether you can fix it after treatment
CO-197: Precertification, authorization or pre-treatment estimate absent. What it means on a dental claim, why dental offices get it, what to do, and whether the patient owes it.
By Dr. Salem Sayegh, general dentist, Glendora, California ·
The short answer: CO-197 means the plan required precertification or authorization for the procedure and none was on file. On dental claims it is most common with Medicaid and some managed care plans, and for major work like crowns, implants, orthodontics or general anesthesia. Some payers accept a retroactive request with full documentation; many do not.
| Code | CO-197 (adjustment reason code) |
|---|---|
| Group | CO, contractual obligation |
| Meaning | A required authorization was not obtained |
| Is it a denial? | Yes |
| Bill the patient? | Usually not when in network |
| Usually fixable? | Sometimes, if the payer allows retroactive authorization |
Why dental offices get CO-197
- Medicaid and some managed care dental plans require prior authorization for crowns, endodontics, orthodontics or sedation.
- The authorization was obtained but expired before treatment.
- The authorized procedure or tooth did not match what was billed.
- A predetermination (pre-treatment estimate) was sent where the plan required an authorization, or the other way round.
What to do about CO-197
- Check whether the plan requires authorization or only offers a voluntary predetermination. They are not the same.
- Ask the payer whether it accepts a retroactive authorization, and if so send the request with radiographs and a narrative.
- If an authorization exists, check that the code, tooth and dates match the claim, and appeal with the authorization number.
- Flag the plan in your software so authorization is requested before the next patient is scheduled.
Can you bill the patient for CO-197?
Usually not, when you are in network: obtaining a required authorization is generally the provider’s responsibility. Check your contract, and for Medicaid patients follow the program’s billing rules.
Questions about a specific EOB line?
Ask Sai Biller, our free dental insurance chatbot. Type the codes and amounts from the line, leave out patient details, and it explains what happened and what to do next. For offices posting every day, Sai for Dentists reads each EOB line as it posts, checks the allowed amount against your contracted fee and lists every denial, downgrade and underpayment for your team.
Sources
- X12 claim adjustment reason codes and remittance advice remark codes. Meanings here are paraphrased; see X12 for the official wording.
- American Dental Association, CDT: Code on Dental Procedures and Nomenclature. Procedure labels here are our own short descriptions.
- Payers apply these codes differently. Your contract and each payer’s provider manual decide what applies to your office.
Common questions
Is a predetermination the same as a preauthorization?
No. A predetermination or pre-treatment estimate tells you what the plan would likely pay and is usually optional. A preauthorization is a requirement for payment on plans that use it. CO-197 is about a required authorization.
Can I get a dental preauthorization after treatment?
Some payers allow retroactive authorization, especially for urgent care, if you send full documentation promptly. Many do not. Ask the payer before appealing.
