CARC 133 Active

PR-133: Service Line Pending Further Review

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-133 Mean?

With PR (Patient Responsibility), the CARC 133 adjustment for service line pending further review 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 133 appears on a remittance when the payer applies an adjustment for service line pending further review. 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 payer has requested additional documentation (medical records, clinical notes, etc.) to complete the adjudication of the claim and is holding the service line pending receipt; The claim has been selected for medical review, prepayment audit, or clinical review, and the payer is holding the payment until the review is completed; The payer is investigating other potential insurance coverage for the patient and is holding the claim pending COB determination. The group code paired with CARC 133 determines who bears the financial responsibility — OA indicates a coordination of benefits or other payer adjustment, CO places it on the provider as a contractual obligation, PR shifts it to the patient.

How to Resolve

  1. Review the adjustment Examine the PR-133 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

Service Line Pending Further Review grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

How to Prevent PR-133

Also Filed As

The same CARC 133 may appear with different Group Codes:

OA-133 CO-133

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

Sources

  1. https://www.cms.gov/medicare/claims-appeals/organization-determinations
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/133
  4. Codes maintained by X12. Visit x12.org for official definitions.