What if we never requested authorization?

Use either the not-required paragraph or the emergent paragraph, whichever the facts support. If neither applies, the appeal is weak — the honest step is to check the payer's published policy before spending time on the letter.

Should I include the clinical record?

Attach it when you are arguing emergent circumstances or when the denial questions the service itself. For a pure authorization-on-file argument, the authorization record does the work and a thick clinical packet just slows review.

CO-197

Appeal letter template: prior authorization absent (CO-197)

For denials asserting no authorization was on file. Works whether the authorization existed, was never required, or the payer missed its own decision deadline.

Free, no signup required to read or copy it. Replace every bracketed field before sending, and refer to the patient by initials and account reference only — never a full name.

Use this when

The remittance shows CO-197 or states precertification or authorization was absent.
An authorization exists but was not matched to the claim.
The service did not require authorization under the member's plan.
Authorization was requested and the payer did not decide within its own timeframe.

The letter

[PRACTICE NAME]
[PRACTICE ADDRESS]
[PHONE] · [FAX]

[DATE]

[PAYER NAME] — Appeals Department
[APPEALS ADDRESS FROM YOUR REMITTANCE]

RE: Appeal of claim denial
Claim number: [CLAIM NUMBER]
Patient reference: [PATIENT INITIALS] / [ACCOUNT REFERENCE]
Date of service: [DATE OF SERVICE]
Billed amount: [AMOUNT]
Denial code: CO-197 — precertification/authorization/notification/pre-treatment absent

To the Appeals Department:

We are appealing the denial of the claim identified above, which was denied on the basis that prior authorization was absent.

[CHOOSE THE PARAGRAPH THAT MATCHES YOUR SITUATION AND DELETE THE OTHERS]

[IF AUTHORIZATION EXISTS] Authorization for this service was obtained prior to the date of service. The authorization reference is [AUTHORIZATION NUMBER], issued [AUTHORIZATION DATE] for [SERVICE / DATE RANGE AUTHORIZED]. The service billed is within the scope of that authorization. We ask that the claim be reprocessed against the authorization already on file.

[IF AUTHORIZATION WAS NOT REQUIRED] The member's plan did not require prior authorization for this service on the date of service. We have reviewed the plan's published authorization requirements and this service is not listed among them. We ask that the denial be withdrawn and the claim processed.

[IF THE PAYER MISSED ITS DECISION WINDOW] A prior authorization request for this service was submitted on [SUBMISSION DATE], reference [REFERENCE NUMBER]. No determination was issued within the plan's stated decision timeframe. We ask that the service be treated as authorized in accordance with the plan's own rules.

[IF THE PRESENTATION WAS EMERGENT] The patient presented under circumstances that did not permit pre-service authorization. Clinical documentation describing the presentation is attached. We ask that retroactive authorization be applied in accordance with the plan's policy for urgent and emergent care.

Attached in support of this appeal:
[LIST ATTACHMENTS — remittance advice, authorization record, submission confirmation, clinical documentation]

We ask that you reprocess this claim and remit payment in the amount of [AMOUNT].

Please provide a written determination within your stated appeal-response window. If any additional documentation would assist the review, contact me directly at [PHONE] or [EMAIL].

Sincerely,

[NAME]
[TITLE]
[PRACTICE NAME]
[NPI / TAX ID]

How to adapt it

Keep only the one situation paragraph that applies and delete the rest — a letter arguing four contradictory positions reads as a form letter.
Put the authorization number in the RE block as well if you have one; it is the single fastest way for a reviewer to resolve the claim.
Never substitute the patient's full name for the initials. The account reference is enough for the payer to locate the claim.

Understand the denial first

CO-197CO-197 denial: prior authorization absentThe payer says the service needed prior authorization and it did not have one on file when the claim was processed.

Common questions

What if we never requested authorization?: Use either the not-required paragraph or the emergent paragraph, whichever the facts support. If neither applies, the appeal is weak — the honest step is to check the payer's published policy before spending time on the letter.
Should I include the clinical record?: Attach it when you are arguing emergent circumstances or when the denial questions the service itself. For a pure authorization-on-file argument, the authorization record does the work and a thick clinical packet just slows review.

Or skip the blanks entirely

Undeny reads the denial document, fills every one of these fields from it, and tracks the appeal deadline. About three minutes instead of thirty.

Generate your appeal letter See pricing