What does the PR227 denial code mean?

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The PR-227 denial code means that information requested from the patient, insured person, or responsible party was not provided, or was insufficient and incomplete.

Breakdown of the Code

  • PR (Patient Responsibility): The group code assigned by the insurance payer. (Note: Despite the "PR" label, this does not automatically mean the patient owes a balance; it indicates that the missing data is the patient or member's responsibility to supply).
  • 227 (Claim Adjustment Reason Code): Specifies that the payer is waiting on details from the member (such as a coordination of benefits questionnaire, accident details, or other insurance verification) and cannot process the claim yet.

Common Triggers

  • Unanswered coordination of benefits (COB) forms sent directly to the patient.
  • Missing accident, employment, or injury questionnaires.
  • Requests for other active health insurance policies that the member failed to verify.

How to Resolve It

  1. Check the Remark Codes: Look at the accompanying Remittance Advice remark codes to see the specific information the insurer requested.
  2. Contact the Patient: Reach out to the patient or insured party directly to explain that the insurance company needs a response or form to process the claim.
  3. Resubmit the Claim: Once the patient provides the requested details to the insurer, follow up and resubmit or appeal the claim with the completed information.

What is the PR 272 denial code?

The PR-272 denial code means that a billed medical service is not covered because the specific coverage or program guidelines of the patient's plan were not met.

What the Code Means

  • PR (Patient Responsibility): The group code shows that the unpaid balance shifts to the patient.
  • 272 (Reason Code): The numeric reason code indicates a mismatch between the service provided and the insurer's criteria, rules, or limits.

Common Causes

  • Unmet Guidelines: The treatment failed to satisfy specific plan rules, limits, or medical necessity requirements.
  • Missing Authorization: A required prior authorization was not obtained before performing the service.
  • Inaccurate Coding or Data: Errors in the billing codes or incorrect patient insurance details caused a policy mismatch.

How to Resolve It

  • Check the Claim: Review the original medical claim for coding or data entry errors.
  • Contact the Payer: Call the insurance provider to ask for the exact missing element or specific rule that triggered the denial.
  • Appeal or Resubmit: Submit an appeal with correct clinical documentation or missing information if the service should have been covered. You can learn more about managing these issues through guides like the Etactics Denial Code Guide.

What does the PR 27 denial code mean?

The PR-27 denial code means "Expenses incurred after coverage terminated," indicating that the patient's insurance policy was inactive or expired on the date the medical service was provided.

Breakdown of the Code

  • PR (Patient Responsibility): The group code showing that the financial obligation falls on the patient rather than the insurance payer.
  • 27 (Claim Adjustment Reason Code): The specific code indicating that the service date occurred after the policy end date.

Common Causes

  • Lapsed coverage: The patient lost coverage due to unpaid premiums, a change in employment, or a plan update.
  • Outdated data: The provider had old or unverified insurance information on file during the visit.
  • Delayed billing: Submission of the claim was delayed past the active coverage termination date.

How to Resolve It

  • Check the dates: Confirm the exact effective and termination dates of the policy with the payer.
  • Look for errors: Check if the date of service was mistyped on the claim.
  • Find secondary insurance: Check if the patient has active secondary or alternative coverage for that date.
  • Bill the patient: If the insurance termination is accurate, update the account to patient responsibility and discuss direct payment options.

What is the PR 275 denial code?

PR-275 means prior payer's patient responsibility (deductible, coinsurance, or co-payment) not covered.

What PR-275 Means

  • Secondary insurance limit: This code usually appears on a secondary insurance Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA).
  • Zero secondary payment: It shows that the secondary plan refuses to pay or absorb the remaining patient responsibility left over by the primary insurance.
  • Lower allowed amount: This happens when the secondary insurance company's allowed amount for the service is equal to or lower than what the primary insurance already paid.

How to Handle PR-275

  • Check plan rules: Review the secondary plan design. Many secondary or tertiary plans do not automatically cover what the primary insurance leaves behind.
  • Compare remittances: Look closely at both the primary and secondary remittance notices to confirm the allowed amounts match expectations.
  • Patient billing: Because the prefix is PR (Patient Responsibility), the remaining balance is generally billed to the patient, subject to state laws and specific plan contracts.
  • Rarely an appeal: This code is rarely an error requiring a formal appeal; it usually just explains how the secondary coordination of benefits processed the claim.

What does this denial code mean?

It looks like you forgot to include the specific denial code.

Medical denial codes typically consist of a group code (like CO for Contractual Obligation or PR for Patient Responsibility) followed by a number (Claim Adjustment Reason Code, or CARC), such as CO-16 or CO-197. These codes explain why an insurance company adjusted, reduced, or refused payment on a claim.

You can review the official definitions and standards using the X12 Claim Adjustment Reason Codes directory.

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9 related questions found

Does rev code 272 need a CPT?

Revenue code 272 (sterile medical/surgical supplies) typically does not require a CPT code, but it may require a HCPCS code depending on specific items (like pass-through devices) and your Payer Policies.

Standard Billing Rules

  • CPT vs. HCPCS: CPT codes describe procedures and professional services, whereas revenue code 272 represents generic facility supply charges. It does not take a CPT code.
  • HCPCS Requirement: Historically, generic supplies under revenue code 272 did not require HCPCS/CPT codes under standard outpatient prospective payment systems (OPPS).
  • Exceptions for Pass-Through/Implants: If the sterile supply or device has been granted pass-through status or falls under specific device categories, a corresponding "C" series or specific HCPCS code is mandatory.

Recent Payer Trends

  • Stricter Denials: Many commercial and private insurance payers have updated guidelines to require specific HCPCS codes for line items under revenue codes 270–272.
  • Check Payer Guidelines: Bailing generic supplies without a HCPCS code can trigger line-item or full-claim rejections with certain insurers, even if traditional Medicare rules exempt them.

What does 272 coverage program guidelines were not met mean?

Denial code "272: Coverage/program guidelines were not met" means the insurance company rejected a medical claim because the service did not satisfy specific policy rules, clinical criteria, or prerequisites.

Common Reasons for Code 272

  • Unmet Clinical Criteria: The patient's chart or diagnosis did not prove the "medical necessity" required by the insurance company.
  • Failed Prerequisites: Specific rules like step therapy (trying a cheaper drug first) or screening frequency windows (e.g., repeating a test too soon) were ignored.
  • Missing Prior Authorization: The procedure was done without getting the insurer's pre-approval first.
  • Coding or Modifier Mismatch: The billing codes or modifiers did not match the payer's exact coverage policy.

Financial Responsibility (PR vs. CO)

  • PR 272 (Patient Responsibility): The insurer decided the patient must pay the bill because the service or guidelines were not properly followed by the provider or covered by the plan.
  • CO 272 (Contractual Obligation): The provider absorbs the cost because the denial resulted from a contractual or administrative error rather than a patient rule violation.

What is denial code PR227?

Denial code PR 227 means that the insurance payer requested information from the patient, insured, or responsible party, and the details provided were missing, incomplete, or never sent.

The prefix PR stands for Patient Responsibility, meaning the payer has assigned the liability or hold to the patient's side because required data is absent. The code 227 is the specific Claim Adjustment Reason Code (CARC) for insufficient or missing requested information.

Common Causes

  • Unanswered COB forms: The patient did not reply to a Coordination of Benefits questionnaire.
  • Missing details: Accident, injury, or primary insurance verification forms were left incomplete by the patient.
  • Unreturned letters: The insurance company mailed a direct request for details to the member, who failed to respond.

How to Resolve It

  • Contact the patient: Reach out to the patient directly and ask them to respond to the insurance company's request for information or forms.
  • Do not bill the patient immediately: Avoid treating this like a standard balance-due bill or sending collections, as the claim is simply paused pending patient details.
  • Resubmit with data: Once the patient provides the necessary information, update the claim or help the patient submit the required forms to the payer for reprocessing.

What is a PR 27?

A PR-27 Denial Code: Patient Responsible is a medical billing message meaning the insurance company denied a claim because the patient received care after their coverage ended.

What the Code Means

  • PR: Stands for Patient Responsibility, which means the patient must pay the bill instead of the insurance company.
  • 27: The official reason code for expenses incurred after coverage terminated.

Common Causes

  • Lapsed coverage: The patient forgot to pay their monthly insurance bill.
  • Job change: The patient left a job and lost their work-based health plan.
  • Outdated files: The doctor's office has old insurance details in their computer.
  • Timing errors: The medical service happened after the official end date of the policy.

How to Resolve It

  • Check dates: Look at the exact date of the doctor visit and compare it to the active insurance dates.
  • Update details: Ask the patient for their new active insurance card and resubmit the claim.
  • Bill the patient: If the insurance is truly inactive, the patient must pay for the visit.

Read more about this in the PR-27 Denial Code Description.

What does denial code PR242 mean?

Denial code PR-242 means the insurance company denied a claim because the service was not provided by a network provider or an approved primary care provider, and the cost is designated as Patient Responsibility (PR).

What the Code Means

  • PR (Patient Responsibility): The insurance will not pay, and the balance is billed directly to the patient instead of being written off by the provider.
  • 242 (CARC 242): The official X12 Claim Adjustment Reason Code for "Services not provided by network/primary care providers."

Common Causes

  • Out-of-network care: The doctor or facility is not part of the patient's insurance network.
  • Missing referral: The patient saw a specialist without getting the required referral from their primary care physician (PCP) first.
  • Plan rules ignored: The patient did not follow specific network guidelines required by their insurance plan.

How to Fix or Resolve It

  • Check the network: Verify if the provider was actually in-network or out-of-network on the date of service.
  • Look for missing referrals: Check if a PCP referral was issued but omitted from the original claim submission.
  • Resubmit or appeal: Correct any billing or coding mistakes and submit supporting documents or an appeal if the denial was a mistake by the payer.