PR (Patient Responsibility) Denial Codes

PR adjustments indicate the patient is financially responsible for the adjusted amount. This includes deductibles, copayments, coinsurance, and non-covered services. The provider can bill the patient for PR amounts.

Common scenarios: Deductible not yet met for the benefit period. Copayment or coinsurance amounts. Non-covered services under the patient's plan. Out-of-network charges above the allowed amount.

Codes: 281 active Financial responsibility: Patient Patient billable: Yes
Disclaimer
This content is for informational purposes only. Always verify against your payer contracts and current coding guidelines.

All PR Denial Codes

Code Name Category Action
PR-1 Deductible Amount patient responsibility Collect from Patient →
PR-2 Coinsurance Amount patient responsibility Collect from Patient →
PR-3 Co-payment Amount patient responsibility Collect from Patient →
PR-4 Procedure Code Inconsistent with Modifier coding error Verify & Resubmit →
PR-5 Procedure Code Inconsistent with Place of Service coding error Verify & Resubmit →
PR-6 Procedure/Revenue Code Inconsistent with Patient Age coding error Review & Decide →
PR-7 Procedure/Revenue Code Inconsistent with Patient Gender coding error Review & Decide →
PR-8 Procedure Code Inconsistent with Provider Type/Specialty coding error Review & Decide →
PR-9 Diagnosis Inconsistent with Patient Age coding error Review & Decide →
PR-10 Diagnosis Inconsistent with Patient Gender coding error Review & Decide →
PR-11 Diagnosis Inconsistent with Procedure coding error Verify & Resubmit →
PR-12 Diagnosis Inconsistent with Provider Type coding error Review & Decide →
PR-13 Date of Death Precedes Date of Service other Review & Decide →
PR-14 Date of Birth Follows Date of Service other Review & Decide →
PR-16 Missing Information or Billing Error information missing Collect from Patient →
PR-18 Exact Duplicate Claim/Service duplicate Review & Decide →
PR-19 Workers' Compensation Claim other Review & Decide →
PR-20 Liability Carrier Responsible other Review & Decide →
PR-21 No-Fault Carrier Responsible other Review & Decide →
PR-22 Coordination of Benefits - Another Payer May Cover other Review & Decide →
PR-23 Prior Payer Adjudication Impact patient responsibility Collect from Patient →
PR-24 Charges Covered Under Capitation/Managed Care other Review & Decide →
PR-26 Expenses Incurred Prior to Coverage coverage Collect from Patient →
PR-27 Expenses Incurred After Coverage Terminated coverage Collect from Patient →
PR-29 Timely Filing Limit Expired timely filing Review & Decide →
PR-31 Patient Cannot Be Identified as Insured other Review & Decide →
PR-32 Patient Not Eligible Dependent coverage Collect from Patient →
PR-33 Insured Has No Dependent Coverage coverage Collect from Patient →
PR-34 No Coverage for Newborns coverage Collect from Patient →
PR-35 Lifetime Benefit Maximum Reached coverage Collect from Patient →
PR-39 Services Denied at Authorization/Pre-certification authorization Collect from Patient →
PR-40 Charges Do Not Meet Emergent/Urgent Care Qualifications coverage Appeal →
PR-44 Prompt-Pay Discount other Review & Decide →
PR-45 Charge Exceeds Fee Schedule/Maximum Allowable fee schedule Collect from Patient →
PR-49 Non-Covered Routine/Preventive Exam coverage Collect from Patient →
PR-50 Non-Covered Service - Not Medically Necessary coverage Collect from Patient →
PR-51 Non-Covered Pre-existing Condition coverage Appeal →
PR-53 Services by Immediate Relative Not Covered coverage Review & Decide →
PR-54 Multiple Physicians/Assistants Not Covered coverage Review & Decide →
PR-55 Procedure/Treatment Deemed Experimental/Investigational coverage Appeal →
PR-56 Procedure/Treatment Not Proven Effective coverage Appeal →
PR-58 Inappropriate or Invalid Place of Service coverage Appeal →
PR-59 Multiple/Concurrent Procedure Rules Applied other Review & Decide →
PR-60 Outpatient Services Not Covered Near Inpatient Stay coverage Review & Decide →
PR-61 Failure to Obtain Second Surgical Opinion authorization Collect from Patient →
PR-66 Blood Deductible patient responsibility Collect from Patient →
PR-69 Day Outlier Amount other Review & Decide →
PR-70 Cost Outlier Adjustment other Review & Decide →
PR-74 Indirect Medical Education Adjustment other Review & Decide →
PR-75 Direct Medical Education Adjustment other Review & Decide →
PR-76 Disproportionate Share Adjustment other Review & Decide →
PR-78 Non-Covered Days / Room Charge Adjustment patient responsibility Collect from Patient →
PR-85 Patient Interest Adjustment patient responsibility Collect from Patient →
PR-89 Professional Fees Removed from Charges other Review & Decide →
PR-90 Ingredient Cost Adjustment patient responsibility Collect from Patient →
PR-91 Dispensing Fee Adjustment other Review & Decide →
PR-94 Processed in Excess of Charges other Review & Decide →
PR-95 Plan Procedures Not Followed authorization Collect from Patient →
PR-96 Non-Covered Charges coverage Collect from Patient →
PR-97 Bundled Service — Not Paid Separately bundling Review & Decide →
PR-100 Payment Made to Patient/Insured other Review & Decide →
PR-101 Predetermination: Anticipated Payment other Review & Decide →
PR-102 Major Medical Adjustment patient responsibility Collect from Patient →
PR-103 Provider Promotional Discount other Review & Decide →
PR-104 Managed Care Withhold other Review & Decide →
PR-105 Tax Withholding Amount other Review & Decide →
PR-106 Patient Payment Option Not in Effect patient responsibility Collect from Patient →
PR-107 Related or Qualifying Service Not Identified other Review & Decide →
PR-108 Rent/Purchase Guidelines Not Met patient responsibility Collect from Patient →
PR-109 Claim Not Covered by This Payer coverage Review & Decide →
PR-110 Billing Date Predates Service Date other Review & Decide →
PR-111 Not Covered Unless Provider Accepts Assignment coverage Review & Decide →
PR-112 Service Not Furnished Directly or Not Documented other Review & Decide →
PR-114 Procedure/Product Not FDA Approved coverage Collect from Patient →
PR-115 Procedure Postponed, Canceled, or Delayed other Review & Decide →
PR-116 Advance Indemnification Notice Requirements Not Met other Review & Decide →
PR-117 Transportation to Nearest Facility other Review & Decide →
PR-118 ESRD Network Support Adjustment other Review & Decide →
PR-119 Benefit Maximum Reached patient responsibility Collect from Patient →
PR-121 Indemnification Adjustment other Review & Decide →
PR-122 Psychiatric Services Reduction patient responsibility Collect from Patient →
PR-128 Newborn Services in Mother's Allowance other Review & Decide →
PR-129 Prior Processing Information Incorrect other Review & Decide →
PR-130 Claim Submission Fee other Review & Decide →
PR-131 Claim-Specific Negotiated Discount other Review & Decide →
PR-132 Prearranged Demonstration Project Adjustment other Review & Decide →
PR-133 Service Line Pending Further Review other Review & Decide →
PR-134 Technical Fees Removed other Review & Decide →
PR-135 Interim Bills Cannot Be Processed other Review & Decide →
PR-136 Failure to Follow Prior Payer's Coverage Rules other Review & Decide →
PR-137 Regulatory Surcharges, Assessments, or Health-Related Taxes other Review & Decide →
PR-139 Contracted Funding Agreement — Subscriber Employed by Provider fee schedule Review & Decide →
PR-140 Patient ID Number and Name Do Not Match other Review & Decide →
PR-142 Monthly Medicaid Patient Liability Amount patient responsibility Collect from Patient →
PR-143 Portion of Payment Deferred other Review & Decide →
PR-144 Incentive Adjustment for Preferred Product/Service other Review & Decide →
PR-146 Diagnosis Invalid for Date of Service information missing Review & Decide →
PR-147 Provider Accepted Reduced Payment from Regulatory Authority other Review & Decide →
PR-148 Information from Another Provider Not Provided or Incomplete information missing Review & Decide →
PR-149 Lifetime Benefit Maximum Reached patient responsibility Collect from Patient →
PR-150 Information Does Not Support Level of Service patient responsibility Review & Decide →
PR-151 Information Does Not Support Frequency of Services other Review & Decide →
PR-152 Information Does Not Support Length of Service other Review & Decide →
PR-153 Information Does Not Support Dosage other Review & Decide →
PR-154 Information Does Not Support Day's Supply other Review & Decide →
PR-155 Patient Refused the Service/Procedure other Review & Decide →
PR-157 Service Provided as Result of Act of War other Review & Decide →
PR-158 Service Provided Outside the United States other Review & Decide →
PR-159 Service Provided as Result of Terrorism other Review & Decide →
PR-160 Benefit Exclusion: Injury from Excluded Activity other Review & Decide →
PR-161 Provider Performance Bonus other Review & Decide →
PR-163 Attachment/Documentation Referenced on Claim Not Received other Review & Decide →
PR-164 Attachment/Documentation Not Received in Timely Fashion other Review & Decide →
PR-166 Payer's Responsibility Ended Before Service Date other Review & Decide →
PR-167 Diagnosis Not Covered patient responsibility Review & Decide →
PR-169 Alternate Benefit Provided other Review & Decide →
PR-170 Payment Denied for This Provider Type other Review & Decide →
PR-171 Payment Denied for Provider Type in This Facility Type other Review & Decide →
PR-172 Payment Adjusted for Provider Specialty other Review & Decide →
PR-173 Service Not Prescribed by a Physician other Review & Decide →
PR-174 Service Not Prescribed Prior to Delivery other Review & Decide →
PR-175 Prescription Is Incomplete information missing Review & Decide →
PR-176 Prescription Is Not Current other Review & Decide →
PR-177 Patient Has Not Met Required Eligibility Requirements patient responsibility Review & Decide →
PR-178 Patient Has Not Met Spend Down Requirements other Review & Decide →
PR-179 Patient Has Not Met Required Waiting Period other Review & Decide →
PR-180 Patient Has Not Met Residency Requirements other Review & Decide →
PR-181 Procedure Code Invalid on Date of Service information missing Review & Decide →
PR-182 Procedure Modifier Invalid on Date of Service coding error Review & Decide →
PR-183 Referring Provider Not Eligible to Refer other Review & Decide →
PR-184 Prescribing/Ordering Provider Not Eligible to Prescribe/Order other Review & Decide →
PR-185 Rendering Provider Not Eligible to Perform Service other Review & Decide →
PR-186 Level of Care Change Adjustment other Review & Decide →
PR-187 Consumer Spending Account Payment Not Approved other Review & Decide →
PR-188 Product/Procedure Not Covered Unless FDA-Recommended coverage Review & Decide →
PR-189 No Specific Procedure Code for Service Billed other Review & Decide →
PR-190 Billing for SNF Qualified Stay Already Covered other Review & Decide →
PR-192 Non-Standard Adjustment Code from Paper Remittance other Review & Decide →
PR-193 Original Payment Decision Maintained on Review other Review & Decide →
PR-194 Anesthesia by Operating/Assistant/Attending Physician other Review & Decide →
PR-195 Refund to Erroneous Priority Payer other Review & Decide →
PR-197 Precertification/Authorization/Notification Absent authorization Review & Decide →
PR-198 Precertification/Authorization Limits Exceeded authorization Collect from Patient →
PR-199 Revenue Code and Procedure Code Mismatch coding error Review & Decide →
PR-200 Expenses Incurred During Lapse in Coverage coverage Collect from Patient →
PR-201 Patient Responsibility via Set-Aside Arrangement patient responsibility Collect from Patient →
PR-202 Non-Covered Personal Comfort or Convenience Services patient responsibility Collect from Patient →
PR-203 Discontinued or Reduced Service other Review & Decide →
PR-204 Service/Equipment/Drug Not Covered Under Benefit Plan coverage Collect from Patient →
PR-205 Pharmacy Discount Card Processing Fee other Review & Decide →
PR-206 National Provider Identifier - Missing information missing Review & Decide →
PR-207 National Provider Identifier - Invalid Format information missing Review & Decide →
PR-208 National Provider Identifier - Not Matched other Review & Decide →
PR-209 Provider Cannot Collect from Patient per Regulatory Agreement other Review & Decide →
PR-210 Pre-Certification/Authorization Not Received Timely authorization Collect from Patient →
PR-211 National Drug Codes (NDC) Not Eligible for Rebate, Not Covered coverage Review & Decide →
PR-212 Administrative Surcharges Not Covered coverage Review & Decide →
PR-213 Non-Compliance with Physician Self-Referral Prohibition authorization Review & Decide →
PR-215 Based on Subrogation of a Third Party Settlement other Review & Decide →
PR-216 Based on Findings of a Review Organization other Collect from Patient →
PR-219 Based on Extent of Injury other Review & Decide →
PR-222 Exceeds Contracted Maximum Hours/Days/Units fee schedule Review & Decide →
PR-223 Mandated Federal/State/Local Law Adjustment other Collect from Patient →
PR-224 Patient Identification Compromised by Identity Theft other Review & Decide →
PR-225 Penalty or Interest Payment by Payer other Review & Decide →
PR-226 Provider Information Not Provided or Insufficient other Review & Decide →
PR-227 Patient/Insured Information Not Provided or Insufficient information missing Collect from Patient →
PR-228 Denied for Failure to Supply Information to Previous Payer information missing Collect from Patient →
PR-229 Partial Charge Not Considered Due to Type of Bill 12X patient responsibility Collect from Patient →
PR-231 Mutually Exclusive Procedures other Review & Decide →
PR-232 Institutional Transfer Amount other Review & Decide →
PR-233 Hospital-Acquired Condition or Preventable Medical Error other Review & Decide →
PR-234 Procedure Not Paid Separately bundling Review & Decide →
PR-235 Sales Tax patient responsibility Collect from Patient →
PR-236 Procedure/Modifier Not Compatible per NCCI coding error Review & Decide →
PR-237 Legislated/Regulatory Penalty other Review & Decide →
PR-238 Claim Spans Eligible/Ineligible Periods - Ineligible Reduction coverage Collect from Patient →
PR-239 Claim Spans Eligible/Ineligible Periods - Rebill Separately other Review & Decide →
PR-240 Diagnosis Inconsistent with Patient's Birth Weight coding error Review & Decide →
PR-241 Low Income Subsidy (LIS) Co-payment Amount patient responsibility Collect from Patient →
PR-242 Services Not Provided by Network/Primary Care Providers patient responsibility Collect from Patient →
PR-243 Services Not Authorized by Network/Primary Care Providers authorization Collect from Patient →
PR-245 Provider Performance Program Withhold other Review & Decide →
PR-246 Non-Payable Code for Required Reporting Only other Review & Decide →
PR-247 Deductible for Professional Service in Institutional Setting patient responsibility Collect from Patient →
PR-248 Coinsurance for Professional Service in Institutional Setting patient responsibility Collect from Patient →
PR-249 Claim Identified as Readmission other Review & Decide →
PR-250 Incorrect Attachment/Documentation Received other Review & Decide →
PR-251 Incomplete or Deficient Attachment/Documentation Received information missing Review & Decide →
PR-252 Attachment Required to Adjudicate Claim other Review & Decide →
PR-253 Sequestration Reduction in Federal Payment other Review & Decide →
PR-254 Dental Plan Benefits Not Available - Submit to Medical other Review & Decide →
PR-256 Service Not Payable Per Managed Care Contract other Review & Decide →
PR-257 Claim Undetermined During Premium Grace Period (HIX) other Review & Decide →
PR-258 Claim Not Covered - Patient in Custody or Incarcerated coverage Review & Decide →
PR-259 Additional Payment for Dental/Vision Service Utilization other Review & Decide →
PR-260 Processed Under Medicaid ACA Enhanced Fee Schedule fee schedule Review & Decide →
PR-261 Procedure Inconsistent with Patient History coding error Review & Decide →
PR-262 Adjustment for Delivery Cost (Pharmaceuticals Only) other Review & Decide →
PR-263 Adjustment for Shipping Cost (Pharmaceuticals Only) other Review & Decide →
PR-264 Adjustment for Postage Cost (Pharmaceuticals Only) other Review & Decide →
PR-265 Adjustment for Administrative Cost (Pharmaceuticals Only) other Review & Decide →
PR-266 Adjustment for Compound Preparation Cost (Pharmaceuticals Only) other Review & Decide →
PR-267 Claim/Service Spans Multiple Months other Review & Decide →
PR-268 Claim Spans Two Calendar Years other Review & Decide →
PR-269 Anesthesia Not Covered for This Procedure coverage Review & Decide →
PR-270 Medical Plan Benefits Not Available - Submit to Dental other Review & Decide →
PR-271 Prior Contractual Reductions on Current Payment Schedule other Review & Decide →
PR-272 Coverage/Program Guidelines Were Not Met other Review & Decide →
PR-273 Coverage/Program Guidelines Were Exceeded other Review & Decide →
PR-274 Fee/Service Not Payable — Care Coordination Arrangement other Review & Decide →
PR-275 Prior Payer Patient Responsibility Not Covered patient responsibility Collect from Patient →
PR-276 Prior Payer Denied Services Not Covered by This Payer coverage Review & Decide →
PR-277 Claim Undetermined During SHOP Exchange Grace Period other Review & Decide →
PR-278 Performance Program Proficiency Requirements Not Met other Review & Decide →
PR-279 Services Not Provided by Preferred Network Providers other Review & Decide →
PR-280 Medical Plan Benefits Not Available - Submit to Pharmacy other Review & Decide →
PR-281 Deductible Waived Per Contractual Agreement patient responsibility Review & Decide →
PR-282 Procedure/Revenue Code Does Not Match Type of Bill other Review & Decide →
PR-283 Attending Provider Not Eligible to Direct Care other Review & Decide →
PR-284 Authorization Valid But Does Not Apply to Billed Services authorization Review & Decide →
PR-285 Appeal Procedures Not Followed other Review & Decide →
PR-286 Appeal Time Limits Not Met other Review & Decide →
PR-287 Referral Exceeded authorization Review & Decide →
PR-288 Referral Absent authorization Review & Decide →
PR-289 Dental and Medical Plans Considered - Benefits Not Available other Review & Decide →
PR-290 Dental Plan Benefits Not Available - Forwarded to Medical other Review & Decide →
PR-291 Medical Plan Benefits Not Available - Forwarded to Dental other Review & Decide →
PR-292 Medical Plan Benefits Not Available - Forwarded to Pharmacy other Review & Decide →
PR-293 Payment Made to Employer other Review & Decide →
PR-294 Payment Made to Attorney other Review & Decide →
PR-295 Pharmacy Direct/Indirect Remuneration (DIR) Adjustment other Review & Decide →
PR-296 Authorization Valid But Does Not Apply to Provider authorization Review & Decide →
PR-297 Medical Plan Benefits Not Available - Submit to Vision other Review & Decide →
PR-298 Medical Plan Benefits Not Available - Forwarded to Vision other Review & Decide →
PR-299 Billing Provider Not Eligible for Payment other Review & Decide →
PR-300 Medical Plan Benefits Not Available - Submit to Behavioral Health other Review & Decide →
PR-301 Medical Plan Claim — Submit to Behavioral Health Plan coverage Verify & Resubmit →
PR-302 Precertification/Authorization Time Limit Expired authorization Collect from Patient →
PR-303 Prior Payer Patient Responsibility Not Covered for QMB coverage Review & Decide →
PR-304 Medical Plan Claim — Submit to Hearing Plan coverage Verify & Resubmit →
PR-305 Medical Plan Claim — Forwarded to Hearing Plan other Review & Decide →
PR-306 Type of Bill Inconsistent with Patient Status coding error Review & Decide →
PR-307 Medicare Maximum Fair Price Standard Default Refund Amount other Review & Decide →
PR-308 Contracted Funding Agreement Adjustment fee schedule Review & Decide →
PR-A0 Patient Refund Amount other Review & Decide →
PR-A1 Claim/Service Denied — Remark Code Required other Collect from Patient →
PR-A5 Medicare PPS Capital Cost Outlier Amount other Review & Decide →
PR-A6 Prior Hospitalization or 30-Day Transfer Requirement Not Met coverage Collect from Patient →
PR-A8 Ungroupable DRG other Review & Decide →
PR-B1 Non-Covered Visits coverage Collect from Patient →
PR-B10 Allowed Amount Reduced — Component of Basic Procedure Already Paid other Review & Decide →
PR-B11 Claim Transferred to Proper Payer — Not Covered Here coverage Collect from Patient →
PR-B12 Services Not Documented in Patient Medical Records information missing Collect from Patient →
PR-B13 Previously Paid — Duplicate Payment duplicate Review & Decide →
PR-B14 Only One Visit/Consultation Per Physician Per Day Covered duplicate Collect from Patient →
PR-B15 Qualifying Service/Procedure Not Received or Covered authorization Collect from Patient →
PR-B16 New Patient Qualifications Not Met coding error Resubmit →
PR-B20 Service Partially or Fully Furnished by Another Provider other Review & Decide →
PR-B22 Payment Adjusted Based on Diagnosis coding error Collect from Patient →
PR-B23 Procedure Not Authorized Per CLIA Proficiency Test other Review & Decide →
PR-B4 Late Filing Penalty timely filing Collect from Patient →
PR-B7 Provider Not Certified/Eligible for This Service on This Date coverage Collect from Patient →
PR-B8 Alternative Services Available — Should Have Been Utilized coverage Collect from Patient →
PR-B9 Patient Enrolled in Hospice other Review & Decide →
PR-P1 State-Mandated Requirement — Property and Casualty Only other Review & Decide →
PR-P10 Payment Reduced to Zero Due to Litigation — P&C Only other Review & Decide →
PR-P11 P&C Claim Disposition Pending Due to Litigation other Review & Decide →
PR-P12 Workers' Compensation Jurisdictional Fee Schedule Adjustment fee schedule Review & Decide →
PR-P13 Payment Reduced/Denied Per WC Jurisdictional Regulations other Review & Decide →
PR-P14 Service Included in Another Service Payment — P&C Only other Review & Decide →
PR-P15 WC Medical Treatment Guideline Adjustment other Review & Decide →
PR-P16 Provider Not Authorized for WC Treatment in This Jurisdiction other Review & Decide →
PR-P2 Not Work-Related — Workers' Compensation Not Liable other Review & Decide →
PR-P3 Workers' Compensation Case Settled — Patient Responsible via MSA patient responsibility Collect from Patient →
PR-P4 Workers' Compensation Claim Non-Compensable other Review & Decide →
PR-P5 Reasonable and Customary Fee Adjustment — P&C Only other Review & Decide →
PR-P6 Adjustment Based on Entitlement to Benefits — P&C Only other Review & Decide →
PR-P7 Billed Code Not in Fee Schedule/Database — P&C Only fee schedule Review & Decide →
PR-P8 Claim Under Investigation — P&C Only other Review & Decide →
PR-P9 No CPT/HCPCS Code Available — P&C Only other Review & Decide →
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Other Group Codes

CO
Contractual Obligation
OA
Other Adjustment
PI
Payor Initiated Reduction