BCBS Prior Authorization Denials: CO-197, CO-198 and CO-284

When this issue appears

This guide is built for provider billing, coding, AR follow-up, and appeals teams working BCBS-related claims. It is especially useful when the EOB gives a short denial reason but the team needs a repeatable action plan.

• Authorization, precertification, notification, referral, or pre-treatment was absent or exceeded.
• The authorization number exists but does not match the billed provider, service, date, units, or location.
• A referral was absent, expired, or exceeded under a network or PCP rule.
• Authorization was obtained through a vendor but not reflected on the claim or local Blue plan record.

Recommended workflow

1. Locate the exact authorization/referral requirement for the member plan and service type.
2. Match the auth record to claim fields: member, CPT/HCPCS, diagnosis, provider, facility, dates, units, and place of service.
3. If the auth was omitted from the claim, follow corrected-claim rules and include the authorization number.
4. If the auth existed but was misapplied, appeal with screenshots, approval letter, call reference, and timeline.
5. For BlueCard claims, confirm whether the local/host plan or member/home plan handled the authorization workflow.

Evidence checklist

• Authorization approval
• Referral record
• Portal screenshot
• Call reference number
• Claim image
• Medical records if clinical criteria are disputed

Related denial codes

Prevention rules for the work queue

• Create a denial work queue by root cause instead of by payer name only.
• Store accepted submission proof, authorization proof, and record-request proof where follow-up staff can retrieve them in seconds.
• Use payer-specific notes for BlueCard, carved-out benefits, authorization vendors, and product-specific medical policies.
• Track overturn rate by code and by evidence type so the team knows which appeals are worth escalating.

FAQ