PR-111: Not Covered Unless Provider Accepts Assignment

What Does PR-111 Mean?

PR-111 means the patient is financially responsible because the provider did not accept assignment. The payer may issue partial payment at the non-participating rate, but the patient owes the remainder. This typically applies to non-participating providers who intentionally did not accept assignment for services where assignment is not mandatory. The patient may face significantly higher out-of-pocket costs compared to an assigned claim.

CARC 111 fires when a payer denies a claim because the provider did not accept assignment for a service that requires it. Assignment means the provider agrees to accept the payer's approved fee schedule amount as payment in full and will not balance bill the patient beyond the allowed coinsurance, copay, or deductible. Certain services — particularly under Medicare — require mandatory assignment regardless of the provider's general participation status.

The most common trigger is Medicare mandatory assignment services. Clinical laboratory services, ambulance services, drugs and biologicals administered by physicians, and services to dual-eligible (Medicare/Medicaid) patients all require assignment under Medicare rules. If the claim does not indicate assignment acceptance, Medicare will deny it with CARC 111 even if the provider is a participating provider. The second major trigger is simply a missing assignment indicator — Box 27 on the CMS-1500 form or the electronic equivalent was not checked, causing the payer to process the claim as non-assigned.

The resolution depends on the Group Code. CO-111 means the provider must absorb the denied amount and correct the claim. PR-111 shifts the financial burden to the patient, typically when the provider is non-participating and the service does not require mandatory assignment. In PR scenarios, the patient pays the full charge because the provider did not agree to accept the payer's allowed amount.

Common Causes

How to Resolve

Verify the provider's participation status and assignment indicator on the claim, correct any errors, and resubmit with assignment accepted if the service requires it.

1. Confirm the PR assignment is appropriate Verify whether the service requires mandatory assignment. If it does, the claim should be corrected and resubmitted as CO-111, not billed to the patient.
2. Check for billing errors If the provider intended to accept assignment and the indicator was simply missing, correct the claim and resubmit before billing the patient.
3. Bill the patient if valid If the provider is non-participating and intentionally did not accept assignment for a non-mandatory service, bill the patient with a clear explanation of charges and the non-participating billing structure.
4. Consider future participation Evaluate whether the provider should become participating with this payer to prevent future PR-111 denials and patient dissatisfaction.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-111:

How to Prevent PR-111

• Inform patients before services are rendered whether the provider accepts assignment with their insurance plan
• Provide patients with an estimate of their out-of-pocket costs when the provider does not accept assignment
• Consider accepting assignment for patients who would face significant financial hardship from non-assigned billing

General Prevention

• Inform patients before services are rendered whether the provider accepts assignment with their specific insurance plan, particularly for non-participating providers
• Provide patients with an estimate of their out-of-pocket costs if the provider does not accept assignment
• Consider accepting assignment for patients who would face significant financial hardship from non-assigned claims

Also Filed As

The same CARC 111 may appear with different Group Codes:

Related Denial Codes