CARC 197 appeal letter template — Missing Precertification/Authorization/Notification
CARC 197 indicates the payer found no record of required precertification, authorization, notification, or pre-treatment review for the billed service. This template helps structure an appeal when evidence exists that the requirement was met or should not have applied.
When to appeal vs. correct & resubmit
Appeal CARC 197 when you have documentation showing authorization/notification was actually obtained, requested timely, or was not required for this service/plan (e.g., emergency care, retro-auth granted, auth number on file but not matched to claim). If no authorization was ever obtained and none of these exceptions apply, correct the claim internally, check whether a retro-authorization request is possible with the payer, and resubmit rather than appeal.
Appeal letter template
Copy the template, replace every [bracketed] field with your details, and keep only the paragraph that fits your situation.
[Date] [Payer Name] Appeals Department [Payer Address] Re: Appeal of Claim Denial — CARC 197 (Precertification/Authorization/Notification/Pre-treatment Absent) Patient Name: [Patient Name] Member ID: [Member ID] Claim #: [Claim #] Date(s) of Service: [DOS] Provider: [Provider Name, NPI] CPT/HCPCS: [CPT/HCPCS] Authorization #: [Authorization #] Dear Appeals Reviewer, This letter appeals the denial of the above claim under CARC 197, which indicates that precertification, authorization, notification, or pre-treatment review was absent for the billed service(s). We respectfully request reconsideration based on the following (select/complete as applicable): [ ] Authorization/notification was obtained prior to service. Authorization number [Authorization #] is referenced above; please confirm this number is correctly linked to the claim. [ ] Authorization/notification was requested on [Date] but not yet finalized by the payer prior to service; confirmation of this request is attached. [ ] The service was rendered on an emergent/urgent basis, for which precertification requirements may not apply; supporting clinical documentation is attached. [ ] The service does not meet the plan's criteria requiring precertification; relevant plan terms or prior payer communication are attached. [ ] A retroactive authorization request has been submitted and is pending/approved; documentation is attached. Enclosed please find supporting documentation referenced above. We ask that the claim for [CPT/HCPCS], date of service [DOS], be reprocessed for payment in light of this information. Please contact our office with any questions or if additional documentation is needed. Sincerely, [Provider Name, NPI] [Practice/Facility Name] [Phone] [Email]
What to attach
- EOB/ERA showing the CARC 197 denial
- Authorization/precertification confirmation (number, approval letter, or portal screenshot)
- Proof of timely authorization request (fax confirmation, call log, submission date/time)
- Clinical documentation supporting emergency/urgent care exception, if applicable
- Retro-authorization request and/or approval documentation, if applicable
- Relevant payer policy or plan document excerpt describing authorization requirements, if available
Frequently asked questions
What does CARC 197 mean?
It means the payer's records show no precertification, authorization, notification, or pre-treatment review on file for the billed service, which the plan required before or around the time of treatment.
Should I appeal or just resubmit the claim?
Appeal if you have proof that authorization/notification existed, was timely requested, or an exception (like emergency care) applies. If none of these apply and no authorization was ever obtained, check for a retro-authorization option first; otherwise this may not be appealable.
What if the authorization number exists but isn't on the claim?
Include the authorization number in your appeal and ask the payer to verify it against the claim, since mismatches or data entry issues are a common cause of this denial.
Is a successful outcome guaranteed?
No. Outcomes depend on payer policy, documentation, and timely filing; this template only helps organize an appeal and does not guarantee any result.
More free billing tools: all appeal letters · denial codes · NCCI edits · Medicare fees
This template is for informational and administrative purposes only and does not constitute legal, medical, or billing advice. It is a general fill-in-the-blank starting point; verify requirements with the specific payer and plan. Appeal outcomes are not guaranteed.
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