Health insurance denial & claim adjustment codes

What health insurance denial code 197 means on your EOB

Your plan says it never received a prior authorization request before the service happened. It is worth checking closely, because the requirement, the timing, and who was responsible for asking can all be established from documents you can obtain.

What usually causes it

• The service may not have required authorization at all — plans revise their lists quarterly, and last year's rule is not this year's.
• The provider may have submitted a request the plan lost, rejected on a technicality, or logged against a different member ID.
• Under an in-network contract, obtaining authorization is usually the provider's obligation, not yours — and that changes who can be billed.

The documents that decide it

• Your EOB, showing code 197 and the date of service.
• Your plan's prior-authorization list as it stood on that date, from the plan's own site.
• Your provider's submission record — the request, its date, and any response.

What to do next

Request the authorization record from your provider before contacting the plan. If they submitted and the plan has no record, that is a plan error and the appeal is short. If they never submitted and were in-network, the balance is likely their write-off rather than yours.

This page explains what a code means. It is information, not advice — it does not tell you whether your specific claim should have been paid, and it is not legal, medical, or insurance advice. Your plan documents and your denial notice govern your situation.