What is Prior authorization?
A payer’s advance approval requirement for certain services, without which the claim is denied after the service is delivered.
Definition
Prior authorization requires the provider to obtain approval before rendering specified services. Requirement lists are payer-specific, plan-specific, and change without much warning, which is what makes compliance hard: the same procedure can require authorization under one plan and not another at the same payer.
When authorization is missing entirely the payer returns CO-197; when an authorization exists but does not match the claim it returns CO-15. The distinction is worth a great deal — CO-15 usually means the approval exists and only the claim is wrong, while CO-197 means the service was delivered without approval and may not be billable to anyone.
Why it matters
Authorization denials arrive after the cost of care has already been incurred, and most contracts bar passing them to the patient. Prevention is the only reliable control.
Denial codes to know
Related terms
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