PI 197 – Precertification, Authorization, Notification, or Referral Not Obtained

The PI-197 denial code indicates that payment was denied or adjusted because the required precertification, prior authorization, notification, or referral was not obtained before the service was provided. The PI (Payer Initiated) group code identifies an adjustment made according to the payer's coverage requirements.

Providers should review the payer's authorization policies and determine whether the denial can be resolved through a corrected claim or appeal.

Quick Facts

Denial Code
PI-197

Group Code
PI (Payer Initiated)

Category
Prior Authorization

Meaning
Required authorization, notification, or referral was not obtained

Common Payers
Medicare, Medicaid, and Commercial Insurance

Next Step
Review authorization requirements and determine whether supporting documentation or an appeal is appropriate

What Does PI-197 Mean?

The PI-197 denial code indicates that the payer requires prior authorization, precertification, notification, or a referral before covering the reported service.

When these requirements are not met, the payer may deny payment even if the service would otherwise be covered.

Common Causes

Providers may receive the PI-197 denial code when:

• Prior authorization was not obtained.

• A required referral was missing.

• Notification requirements were not met.

• Authorization expired before the service date.

• The incorrect authorization number was submitted.

How To Resolve PI-197

If you receive the PI-197 denial code:

• Review the payer's authorization requirements.

• Verify whether authorization was obtained.

• Confirm authorization dates and approval numbers.

• Submit supporting documentation if available.

• Appeal the denial when documentation supports payment.

Common Billing Mistakes

Common issues associated with PI-197 include:

• Performing services before authorization approval.

• Missing referral documentation.

• Expired authorization approvals.

• Incorrect authorization numbers.

• Failure to verify payer requirements before treatment.

Frequently Asked Questions

Can providers appeal a PI-197 denial?

Yes. If authorization was obtained or documentation supports an exception, an appeal may be appropriate.

Does every service require prior authorization?

No. Authorization requirements vary by payer, health plan, and the specific service provided.

Can an expired authorization cause PI-197?

Yes. Services performed after an authorization expires may result in this denial code.

How can providers prevent PI-197 denials?

Verify authorization requirements before treatment, obtain approvals when required, and document authorization numbers in the patient's record.

Related PI Codes

You may also encounter:

• PI-204 Denial Code

• PI-96 Denial Code

• PI-22 Denial Code

• PI-16 Denial Code

Quick Summary

The PI-197 denial code indicates that required prior authorization, notification, precertification, or referral requirements were not met before services were provided. Verifying payer requirements and obtaining authorization before treatment can help prevent future denials.