# CARC 197 denial code on dental claims > What does denial code CARC 197 mean on a dental claim, and can it be appealed? URL: https://dentovio.com/dental-claim-denial-codes/carc-197 Last verified: 2026-08-30 Dentovio is an independent publisher — not a payer, the ADA, X12, CAQH CORE, or any government agency. Code meanings and remark-code meanings on this page are Dentovio's own wording, written from the official X12 Claim Adjustment Reason Code and Remittance Advice Remark Code lists and linked back to them; X12 holds the copyright in those lists and its descriptions are not reproduced here. CDT codes are referenced by number only; CDT is the American Dental Association's copyrighted code set and this page does not reproduce ADA descriptors. Appealability verdicts are Dentovio editorial classification, not a standard. Every fact traces to the code steward's registry, a federal rule or manual, a HIPAA operating rule, an association publication, or a named payer's own document — never to a billing blog. This page was drafted with AI assistance and verified against the primary sources linked here. It has not been reviewed by a credentialed dental billing specialist, attorney, or clinician. Educational billing reference only — not billing, legal, or clinical advice. Plan contracts control individual outcomes, and processing policies usually live in the payer's provider manual rather than in the signed agreement. ## Direct answer On a dental remittance, CARC 197 means: A plan-required pre-service step was not completed, such as approval, certification, notice, or treatment review. X12 assigns it no group code, so the group code on the remittance is the payer's choice under its own contract and it, not the CARC, decides who is assigned the balance. No source read for this page pairs a specific remark code with it. Dentovio's appealability verdict — depends: check the facts first. Search for evidence the authorization exists before conceding: a reference number, a portal record, a call log. Where authorization genuinely was not obtained, be realistic about back-dating — the one dental programme with a published exception path allows it only in narrow circumstances such as back-dated eligibility, requires the request within 90 days of treatment, guarantees nothing, and states plainly that approvals will not be issued because the provider forgot or did not realise approval was needed. Florida adds a payer-side rule for 2025-renewed contracts: a claim for a procedure specifically included in a prior authorization cannot be denied except in enumerated circumstances. Registry entry: X12 Claim Adjustment Reason Code 197 — in the code set since 2006-10-31; description last revised 2018-05-01; active, with no deactivation date. Read on the list published 2025-11-01. Group code: X12 assigns 197 no group code. CMS makes CO contingent on a contractual agreement or a regulatory requirement, so whether a missed authorization becomes a write-off is a contract question rather than a property of the code, and out-of-network or member-notified situations can land as patient responsibility instead. A group code always travels with a CARC, and it — not the CARC — assigns financial responsibility, so read the one on your remittance rather than assuming. Offices commonly write this one as CO 197; that is search shorthand, not a statement that the payer will use CO. ## What it means in dental context Common on implants, orthodontics, and major restorative under plans that require pre-treatment review — and on Medicaid dental programmes with authorization rules (Delta Dental of Washington requires prior authorization for SRP at ages 13–18 under Apple Health, per its published criteria). Prior approval is genuinely required for implants and orthodontics in named state programmes — New York Medicaid says so in its dental manual — while other procedures need approval only past a frequency threshold rather than routinely. Two facts from that manual travel with any authorization discussion: approval does not guarantee payment, and deviating from an approved plan can void the approval entirely and expose the payment to recoupment. Worth noting how thinly payers document the pairing: in MassHealth's whole published crosswalk, CARC 197 appears once, with no remark code at all. ## Appealability: Depends — check the facts first The appealability verdicts on these pages are Dentovio's editorial classification. No standards body or payer publishes an appealability taxonomy: X12 defines what a code means, not what to do about it. Each verdict is built from the code's own mechanics and the payer and federal documents cited on the page, and it is a starting point for triage rather than a prediction of any outcome. A valid contract term may control, while a factual error may be contested. Run the checks on this page before using the appeal window. Search for evidence the authorization exists before conceding: a reference number, a portal record, a call log. Where authorization genuinely was not obtained, be realistic about back-dating — the one dental programme with a published exception path allows it only in narrow circumstances such as back-dated eligibility, requires the request within 90 days of treatment, guarantees nothing, and states plainly that approvals will not be issued because the provider forgot or did not realise approval was needed. Florida adds a payer-side rule for 2025-renewed contracts: a claim for a procedure specifically included in a prior authorization cannot be denied except in enumerated circumstances. ## What to do 1. Search call logs and portals for an authorization reference number before conceding 2. Check whether the procedure needed routine approval at all, or only past a frequency threshold 3. If treatment is already rendered, check whether the payer publishes a back-dating exception and what its window is — provider oversight is usually excluded 4. For a Florida contract delivered, issued, or renewed on or after January 1, 2025, read Fla. Stat. §627.6131(21) if the denied procedure was inside an approved prior authorization — it lets the insurer deny anyway only on the grounds listed there ## Remark codes No source read for this page pairs a remark code with CARC 197. X12 defines no CARC-to-RARC pairings at all: payer crosswalks are specific to that payer's own internal reason codes, and the CAQH CORE combination list binds only payers operating inside its business scenarios. Read the remark code on your own remittance. ## Read with this code - [CARC 96 — Not a covered benefit](https://dentovio.com/dental-claim-denial-codes/carc-96/index.html.md) - [CARC 95 — Plan rules not followed](https://dentovio.com/dental-claim-denial-codes/carc-95/index.html.md) ## Sources - X12 Claim Adjustment Reason Codes (external code list 139) (list updated 2025-11-01): - X12 Remittance Advice Remark Codes (external code list 411) (list updated 2026-07-01): - 45 CFR 162.1602 — HIPAA adoption of the 835 remittance standard that carries these codes: - New York State Medicaid Dental Policy and Procedure Code Manual, Version 2026 (effective 2026-01-01) (prior-approval rule p. 11; back-dated prior approval p. 19; non-surgical periodontal services pp. 36–37): - MassHealth — Claim Adjustment Reason Codes and Remittance Advice Remark Codes crosswalk (posted 2026-02-12) (EOB 2622, p. 28): - Fla. Stat. §627.6131 — Payment of claims (2025) (subsection (21), retroactive denial of a prior-authorized dental procedure; applies to contracts delivered, issued, or renewed on or after 2025-01-01): ## Related - [Dental billing and claims hub](https://dentovio.com/dental-billing/index.html.md) - [All dental denial codes](https://dentovio.com/dental-claim-denial-codes/index.html.md) - [Payer documentation requirements](https://dentovio.com/dental-claim-documentation/index.html.md) - [Dental insurance prompt-pay laws by state](https://dentovio.com/dental-prompt-pay-laws/index.html.md) - [Dental claim appeal letters](https://dentovio.com/dental-claim-appeal-letters/index.html.md)