CARC 136 Active

PR-136: Failure to Follow Prior Payer's Coverage Rules

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-136 Mean?

With PR (Patient Responsibility), the CARC 136 adjustment for failure to follow prior payer's coverage rules 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 136 appears on a remittance when the payer applies an adjustment for failure to follow prior payer's coverage rules. 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 secondary payer denies the claim because the provider did not follow the primary payer's coverage rules or the information from the primary payer's adjudication is missing; The secondary claim does not include the primary payer's Explanation of Benefits or payment details required for proper coordination of benefits processing; The primary payer denied the claim for a compliance reason (e.g., no auth), and the secondary payer will not pay because the primary's coverage rules were not met. The group code paired with CARC 136 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-136 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

Failure to Follow Prior Payer's Coverage Rules 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-136

Also Filed As

The same CARC 136 may appear with different Group Codes:

OA-136 CO-136

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/coordination-of-benefits
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/136
  4. Codes maintained by X12. Visit x12.org for official definitions.