What does PR 197 mean?

The payer says no prior authorisation was on file. Patient responsibility. This one goes on the patient statement.

Why does PR 197 happen?

No authorisation was requested before the service. An authorisation existed but had expired before the date of service. The CPT billed does not match the CPT on the authorisation. Authorisation was obtained under a different plan or payer than the one billed.

What documentation wins a PR 197 appeal?

The authorisation number and its approval date. The retro-authorisation request and the payer's response to it. Documentation that the service was urgent or emergent, where the payer waives auth for those.

PR 197 denial code description — what it means and how to appeal it

Q: Can you appeal PR 197?

Usually recoverable. Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.

What PR 197 means

PR: Patient responsibility. This one goes on the patient statement.

So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.

The same code, a different prefix. 197 also arrives as CO 197. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says CO 197, read that page instead.

Is it worth appealing?

Usually recoverable. Appeal it. The money is usually there.

Why it fires

In the order we see it.

No authorisation was requested before the service.
An authorisation existed but had expired before the date of service.
The CPT billed does not match the CPT on the authorisation.
Authorisation was obtained under a different plan or payer than the one billed.

What to do

Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.

What actually wins it

The documentation, not the argument.

The authorisation number and its approval date.
The retro-authorisation request and the payer's response to it.
Documentation that the service was urgent or emergent, where the payer waives auth for those.

The common mistake. Do not appeal before checking whether a retro-authorisation window is still open. Retro-auth is faster, higher yield and does not spend the appeal.

Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.

PR 197 description

The payer says no prior authorisation was on file. So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.

This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.

PR 197 denial code