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CO-197 and CO-198: the drug was not authorized, or the claim does not match the authorization

CO-197 · N54 · drug and administration lines · fix · appeal

CO-197 means the payer has no authorization on file for the drug on this date; CO-198 means it has one but the claim went past it — more units, more dates, a different dose, a different site, a different diagnosis (N54). Both are administrative denials, and both have a window in which they are usually recoverable.

Reviewed Sep 20, 2026 · maintained by Erin Rose · general reference, not legal advice

What the remit says

CO-197 — “Precertification/authorization/notification/pre-treatment absent.”

Usually with: N54 “Claim information is inconsistent with pre-certified/authorized services”.

Verbatim, X12 code lists 11/1/2025.

Why it lands on drug claims

The first thing to establish is whether the authorization exists and what it says. Most specialty-drug auths are written to a J-code, a dose or units per period, a number of administrations, a date span and a place of service. A claim that changes any one of those — a dose increase, an extra visit, a switch from office to hospital outpatient — returns CO-198 with N54 even though the drug is approved. Amend the auth, then resubmit.

A CO-197 with no auth on file is either a missed request or an auth that was obtained under a different identifier (the wrong NPI, a facility auth for a physician claim, the biosimilar's code instead of the reference product). Payers keep an authorization-lookup line; use it before you file anything.

Where the auth genuinely was not obtained, the remedy is the payer's retroactive-authorization policy — many allow a request within a set number of days after the date of service for urgent care or first doses, and some state laws limit a payer's ability to deny an authorized service after the fact. The gold-card statutes on this site exempt qualifying providers from PA in a few states; they do not rescue a claim filed without one where PA was required.

The fix

What to attach

Corrected claim or appeal?

Neither, at first: it is an authorization fix. CO-198 with a mismatch gets an auth amendment, then a resubmission. CO-197 with no auth gets a retro-authorization request inside the payer's window. Appeal only after the retro request is decided.

Medicare windows (redetermination 120 days, reconsideration 180 days, ALJ 60 days) and the commercial path are on the denials hub, cited to 42 CFR Part 405 Subpart I; the edits are CMS's NCCI tables.

Frequently asked

The payer approved the drug. How can it deny CO-198?
Because the approval was for a specific quantity. An auth for 6 administrations at 100 mg covers exactly that; the seventh visit or a 150 mg dose is outside it. Amend the auth before resubmitting — N54 tells you it is the claim that no longer matches.
Does a gold-card exemption stop CO-197?
Only for a provider who has qualified under the state program, for the services the exemption covers, on a plan the state regulates. Four states have an in-force gold-card law; the exemption is a status the payer confirms, not a defense to a missing auth.
Can the payer deny a service it authorized?
For the authorized service as authorized, most payer contracts and several state laws say no except for eligibility lapses or fraud. Payers do deny authorized services for coding reasons (a different J-code than authorized, units outside the auth) — which is CO-198, and is fixable.

Related references

Payer PA playbooksUHC, Aetna, Cigna, Humana specialty-drug authorization rulesGold-card laws by stateThe four states with a real PA exemption, and who it missesSelf-funded vs fully-insuredWhether any state PA law reaches the planAll drug-claim denialsThe ten denials that land on infusion and injection claims

Know the payer's PA rules before the first dose

Coverage Check shows the prior-authorization requirement, the covered diagnoses and the site-of-care rule for the drug at the patient's payer — before the CO-197 exists.

Open Claim Check

Sources & how this is maintained

Computed on this page
Nothing — this denial has no table fact; the code text is verbatim X12. Edits vintage Q3 2026.
Authored
The five ways an approved drug still returns CO-198, the wrong-identifier CO-197, and the retro-auth window.
Corrections
Send one with the remit line.