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: 90 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-16 Missing Information or Billing Error information missing Collect from Patient →
PR-26 Expenses Incurred Prior to Coverage coverage Collect from Patient →
PR-27 Expenses Incurred After Coverage Terminated coverage Collect from Patient →
PR-32 Patient Not Eligible as Dependent coverage Collect from Patient →
PR-33 Insured Has No Dependent Coverage coverage Collect from Patient →
PR-34 No Newborn Coverage coverage Collect from Patient →
PR-35 Lifetime Benefit Maximum Reached coverage Collect from Patient →
PR-39 Services Denied at Pre-Certification authorization Collect from Patient →
PR-40 Charges Not Qualifying as Emergent/Urgent Care coverage Collect from Patient →
PR-45 Charge Exceeds Fee Schedule / Maximum Allowable fee schedule Review & Decide →
PR-49 Routine/Preventive Exam Not Covered patient responsibility Collect from Patient →
PR-50 Non-Covered Services / Medical Necessity Denial patient responsibility Collect from Patient →
PR-51 Pre-Existing Condition Exclusion patient responsibility Collect from Patient →
PR-55 Experimental / Investigational Procedure patient responsibility Collect from Patient →
PR-56 Procedure / Treatment Not Deemed Effective patient responsibility Collect from Patient →
PR-58 Invalid Place of Service / Treatment Setting Mismatch patient responsibility Collect from Patient →
PR-61 Second Surgical Opinion Not Obtained patient responsibility Collect from Patient →
PR-66 Blood Deductible patient responsibility Collect from Patient →
PR-78 Non-Covered Days / Room Charge Adjustment patient responsibility Collect from Patient →
PR-85 Patient Interest Adjustment patient responsibility Collect from Patient →
PR-90 Ingredient Cost Adjustment patient responsibility Collect from Patient →
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 Collect from Patient →
PR-102 Major Medical Adjustment patient responsibility Collect from Patient →
PR-106 Patient Payment Option Not in Effect patient responsibility Collect from Patient →
PR-108 Rent/Purchase Guidelines Not Met patient responsibility Collect from Patient →
PR-111 Not Covered Unless Provider Accepts Assignment patient responsibility Collect from Patient →
PR-112 Service Not Furnished Directly or Not Documented other Review & Decide →
PR-114 Procedure/Product Not FDA Approved patient responsibility Collect from Patient →
PR-116 Advance Indemnification Notice Requirements Not Met patient responsibility Collect from Patient →
PR-119 Benefit Maximum Reached patient responsibility Collect from Patient →
PR-122 Psychiatric Services Reduction patient responsibility Collect from Patient →
PR-142 Monthly Medicaid Patient Liability Amount patient responsibility Collect from Patient →
PR-149 Lifetime Benefit Maximum Reached coverage Collect from Patient →
PR-153 Documentation Does Not Support Prescribed Dosage other Review & Decide →
PR-154 Documentation Does Not Support Day's Supply of Medication/Supplies other Review & Decide →
PR-158 Service Provided Outside the United States coverage Collect from Patient →
PR-160 Benefit Exclusion — Activity-Related Injury/Illness coverage Collect from Patient →
PR-167 Diagnosis Not Covered coverage Collect from Patient →
PR-169 Alternate Benefit Provided coverage Collect from Patient →
PR-170 Payment Denied — Provider Type Not Eligible other Collect from Patient →
PR-171 Payment Denied — Provider Type in This Facility Type other Collect from Patient →
PR-172 Provider Specialty Adjustment patient responsibility Collect from Patient →
PR-177 Patient Eligibility Requirements Not Met patient responsibility Collect from Patient →
PR-178 Spend Down Requirements Not Met patient responsibility Collect from Patient →
PR-179 Waiting Requirements Not Met patient responsibility Collect from Patient →
PR-180 Residency Requirements Not Met patient responsibility Collect from Patient →
PR-186 Level of Care Change Adjustment patient responsibility Collect from Patient →
PR-187 Consumer Spending Account Payment Not Approved patient responsibility Collect from Patient →
PR-188 Product/Procedure Not Covered Unless FDA-Recommended coverage Review & Decide →
PR-192 Non-Standard COB Adjustment Code other Review & Decide →
PR-193 Original Payment Decision Maintained patient responsibility Collect from Patient →
PR-197 Precertification/Authorization/Notification Absent authorization Collect from Patient →
PR-198 Precertification/Authorization Limits Exceeded authorization Collect from Patient →
PR-200 Expenses Incurred During Lapse in Coverage coverage Collect from Patient →
PR-201 Workers' Comp Settlement — Patient Responsibility per Agreement patient responsibility Collect from Patient →
PR-202 Non-Covered Personal Comfort or Convenience Services coverage Collect from Patient →
PR-203 Discontinued or Reduced Service other Collect from Patient →
PR-204 Service/Equipment/Drug Not Covered Under Benefit Plan coverage Appeal →
PR-210 Pre-Certification/Authorization Not Timely authorization Collect from Patient →
PR-211 NDC Not Eligible for Rebate / Not Covered coverage Collect from Patient →
PR-212 Administrative Surcharges Not Covered coverage Review & Decide →
PR-216 Review Organization Findings coverage Collect from Patient →
PR-223 Mandated Federal/State/Local Law Adjustment other Collect from Patient →
PR-227 Patient/Insured Information Not Provided information missing Collect from Patient →
PR-228 Information Not Provided to Previous Payer information missing Collect from Patient →
PR-229 Medicare Partial Charge on 12X Bill Type other Verify & Resubmit →
PR-235 Sales Tax Not Reimbursable fee schedule Collect from Patient →
PR-238 Ineligible Coverage Period Reduction coverage Collect from Patient →
PR-241 Low Income Subsidy Co-payment Adjustment patient responsibility Collect from Patient →
PR-242 Services Not Provided by Network Provider coverage Collect from Patient →
PR-243 Services Not Authorized by Network Provider authorization Collect from Patient →
PR-247 Professional Service Deductible on Institutional Claim patient responsibility Collect from Patient →
PR-248 Professional Service Coinsurance on Institutional Claim patient responsibility Collect from Patient →
PR-269 Anesthesia Not Covered for This Service patient responsibility Collect from Patient →
PR-272 Coverage/Program Guidelines Not Met patient responsibility Collect from Patient →
PR-273 Coverage/Program Guidelines Exceeded patient responsibility Collect from Patient →
PR-275 Prior Payer's Patient Responsibility Not Covered patient responsibility Collect from Patient →
PR-279 Services Not Provided by Preferred Network Providers patient responsibility Collect from Patient →
PR-284 Authorization Valid but Not Applicable to Billed Services authorization Collect from Patient →
PR-287 Referral Exceeded authorization Collect from Patient →
PR-B1 Non-Covered Visits coverage Collect from Patient →
PR-B11 Claim Transferred to Proper Payer coverage Verify & Resubmit →
PR-B22 Payment Adjusted Based on Diagnosis coding error Collect from Patient →
PR-B7 Provider Not Certified/Eligible coverage Collect from Patient →
PR-P3 Workers' Compensation Case Settled — Patient Responsibility patient responsibility Collect from Patient →
No codes match your search.

Other Group Codes

CO
Contractual Obligation
OA
Other Adjustment
PI
Payor Initiated Reduction