PR-197 Denial Code: Precertification Absent, Patient Responsible

What is the PR-197 denial code? PR-197 is CARC 197 (missing precertification or prior approval) reported with the Patient Responsibility group, meaning the payer holds the member, not the provider, liable for the service it refused to pay.

Undeny's Take

With PR-197 the interesting part is the PR, not the 197. When a contracted provider owns the authorization, a missing approval is a contractual problem, which is what CO-197 expresses. PR means the payer decided the patient owned it. Cigna, for example, tells members that if they don't use a provider in the plan's network, "you are responsible for obtaining the prior authorization." So the first question is whether you were in network. If you were, a patient-responsibility authorization denial deserves a hard look at your participation agreement before anyone sends a statement. On Medicare Advantage the bar is even clearer: CMS says the beneficiary "should not be penalized" when a network physician skipped the plan's pre-authorization procedures.

Patient Liability: What the PR Group Adds to Reason 197

The official X12 description is: "Precertification/authorization/notification/pre-treatment absent." CMS defines the PR group as an adjustment that "may be billed to the patient or insured," and the CO group as an adjustment that is generally "a write off for the provider." That single letter pair is why the PR version of this denial lands on the patient's statement while the CO version stays in your write-off column.

HealthCare.gov's definition is worth remembering on both sides: a plan may require preauthorization before certain services, except in an emergency, but "preauthorization isn't a promise" the plan will pay.

When Plans Put the Approval Duty on the Member

• Out-of-network care where the member had to get the approval. Cigna warns members that without it "the treatment or medication might not be covered, or you may need to pay more out of pocket."
• A plan-level precertification penalty. X12's published interpretation RFI 1869 walks through a payer that applies an out-of-network penalty when precertification is not obtained and messages it on the eligibility (271) response. When a payer reports a penalty that way, your eligibility check can surface it before the visit.
• An authorization existed but never reached the claim. Noridian's Medicare DME contractor lists a missing prior-authorization tracking number on the claim as a common cause of CARC 197, fixed by rebilling with the number.
• A questionable group code. If you are in network and the authorization was your job under the contract, a PR assignment is worth questioning.

Working a Member-Liability Authorization Denial

1. Confirm network status and who was responsible for the authorization under the patient's plan and your contract.
2. Search for an existing authorization: number, date span, approved codes and units. If one covered the service, send a corrected claim with the number in the prior authorization field (Noridian's DME guidance uses Item 23 on the CMS-1500 or loop 2300 REF with the G1 qualifier electronically).
3. Ask the plan whether it accepts a retroactive authorization request for the date of service, and document the answer.
4. For Medicare Advantage claims from a contracted provider, cite CMS's plan-directed care rule, which limits the enrollee to the applicable cost-sharing for a service they reasonably believed was covered.
5. If the plan correctly placed the duty on the patient, bill the PR amount with the EOB, or help the patient appeal on medical necessity. To contest the denial yourself, draft it with the appeal generator.

PR-197 Versus CO-197, 198, 39 and PR-204

CO-197 is the same missing-authorization reason with provider liability. CARC 198 means an authorization existed but was exceeded, for example more visits or units than approved. CARC 39 means the service was denied at the time authorization was requested, so the issue is the payer's decision, not a missing request. PR-204 means the service is not covered under the plan at all. If the remittance also shows a missing-information code such as CO-16, fix the claim data first. Payer-specific steps are in the Cigna and Aetna appeal guides.

Frequently Asked Questions

What is the difference between PR-197 and CO-197?

Both mean the required precertification or authorization was absent. CO-197 makes the amount a contractual write-off for the provider, while PR-197 assigns it to the patient. The group code reflects who the payer believes was responsible for getting the approval.

Can I bill the patient for a PR-197 denial?

The PR group allows it, but check two things first. Make sure the plan actually placed the authorization duty on the member, as Cigna does for out-of-network care, and that your contract does not hold patients harmless for authorization failures. On Medicare Advantage, a contracted provider's missed pre-authorization should not be charged to the enrollee beyond cost-sharing.

What if an authorization was on file but the claim still denied PR-197?

Treat it as a claim data problem. Rebill with the authorization number in the prior authorization field and confirm the dates, codes and units match what was approved. If the authorization covered fewer units than billed, the payer may report CARC 198 (authorization exceeded) for the excess instead.

Can a patient appeal a PR-197 denial?

Generally yes. HealthCare.gov states that when an insurer refuses to pay a claim, the member has the right to appeal and to have the decision reviewed by a third party. The provider can support that appeal with records showing the service was medically necessary and an explanation of why authorization was missing.

Informational only, not legal, medical, or billing advice. Always verify against your current payer contract and policy.

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