CARC 109 Active

PR-109: Claim Not Covered by This Payer

TL;DR

Patient responsibility — review the adjustment and determine if the patient truly owes this amount.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-109 Mean?

With PR (Patient Responsibility), the CARC 109 adjustment for claim not covered by this payer shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

CARC 109 appears on a remittance when the payer applies an adjustment for claim not covered by this payer. Review the group code and any accompanying RARC codes to understand the full context of this adjustment.

Common scenarios that trigger this adjustment include: the claim was sent to a MAC that does not have jurisdiction over the provider's geographic area or service type, and must be resubmitted to the correct MAC; The patient's insurance coverage is with a different plan or payer than the one the claim was submitted to; The specific service type (Part A vs. Part B, DME vs. professional) was submitted to a payer that does not process that category of claims. The group code paired with CARC 109 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

How to Resolve

  1. Review the adjustment Examine the PR-109 adjustment and any RARC codes to understand the basis for the patient responsibility.
  2. Verify the adjustment is correct Confirm the PR designation and amount are appropriate based on the patient's plan benefits.
  3. Appeal if incorrect If the adjustment appears incorrect, file an appeal with supporting documentation.
  4. Collect from the patient if valid If the adjustment is confirmed correct, generate a patient statement and follow standard collection procedures.
Do Not Appeal This Code

The claim was submitted to the wrong payer or contractor. Resubmit to the correct payer rather than appealing this determination.

How to Prevent PR-109

Also Filed As

The same CARC 109 may appear with different Group Codes:

CO-109 OA-109

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns

Sources

  1. https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/109
  4. Codes maintained by X12. Visit x12.org for official definitions.