The denial you can see coming
CO-197 — no authorization — is one of the most avoidable denials there is, and one of the most common. It shows up most in mental and behavioral health, where session limits and concurrent review let authorizations lapse mid-course, and in physical therapy, where approval runs out before the plan of care does.
Filing the request is the easy part. Most authorizations are lost to silence: a request sits unanswered, the visit goes ahead, and the claim is denied weeks later.
How we handle authorizations
Each request has an owner and a status until the payer answers.
- Requirements identified during eligibility verification
- Requests filed with the clinical documentation the payer asks for
- Follow-up until approval, denial or a request for more information
- Approved units and date ranges tracked against the schedule
- Renewals started before the current authorization runs out
Connected to the rest of the cycle
Authorization status is visible to the people coding and submitting the claim, so nothing goes out without the approval number it needs. When a payer denies for authorization anyway, the appeal is written by the same team that filed the request — with the paper trail already in hand.
Where authorizations are usually required
Requirements vary by payer and plan, but the same services come up again and again: ongoing outpatient therapy beyond an initial visit allowance, psychological testing, advanced imaging, physical and occupational therapy plans of care, specialty drugs and many procedures. Medicaid managed-care and Medicare Advantage plans tend to require more than traditional Medicare. We check the rule for the specific plan and service rather than relying on what was true last year.