CARC 167 Active

PR-167: Diagnosis Not Covered

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-167 Mean?

With PR (Patient Responsibility), the diagnosis not covered is the patient's financial obligation. The insurer processed the claim, applied the patient's plan benefits, and this amount is owed directly by the patient. The most common scenario is the payer determined the diagnosis is not a covered benefit, and the full cost is the patient's responsibility.

CARC 167 indicates diagnosis not covered. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: the patient's insurance plan specifically excludes coverage for the submitted diagnosis, such as cosmetic conditions, certain mental health diagnoses, or experimental conditions; While the diagnosis itself may be covered, the payer does not consider it a covered indication for the specific procedure or service that was billed; The diagnosis code submitted does not accurately represent the patient's condition, and the code used happens to be excluded from coverage. The group code paired with CARC 167 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

Cause Frequency
Non-covered diagnosis shifted to patient The payer determined the diagnosis is not a covered benefit, and the full cost is the patient's responsibility Most Common

How to Resolve

  1. Review the adjustment Examine the PR-167 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

Diagnosis Not Covered represents an amount the patient owes per their plan benefits — usually a deductible, coinsurance, or copay calculated against plan terms. Since the calculation comes from the benefits rather than a coverage denial, appeals don't apply. Verify the calculation against the patient's plan and collect the patient portion.

How to Prevent PR-167

Also Filed As

The same CARC 167 may appear with different Group Codes:

CO-167 OA-167

Related Denial Codes

PR-1 — Deductible Amount PR-2 — Coinsurance Amount PR-3 — Co-payment Amount PR-23 — Prior Payer Adjudication Impact PR-66 — Blood Deductible

Sources

  1. https://www.mdclarity.com/denial-code-carcs
  2. https://x12.org/codes/claim-adjustment-reason-codes
  3. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  4. https://medicaid-documents.dhhs.utah.gov/Documents/pdfs/ClaimDenialCodes.pdf
  5. Codes maintained by X12. Visit x12.org for official definitions.