PR-178: Patient Has Not Met Spend Down Requirements

What Does PR-178 Mean?

With PR (Patient Responsibility), the unmet spend down amount is assigned to the patient. The patient is financially responsible for services rendered before their spend down threshold was satisfied. This is functionally similar to a deductible — the patient pays until the threshold is met.

CARC 178 appears when a patient's Medicaid eligibility is contingent on meeting a monthly spend down requirement and that threshold has not yet been reached. Spend down works similarly to a deductible — the patient must incur a specified dollar amount of medical expenses each month before Medicaid coverage activates.

This code is specific to Medicaid programs that use spend down as an eligibility mechanism. The patient's income exceeds the Medicaid threshold, but they qualify for coverage once their medical expenses bring their effective income below the limit. Until the patient submits enough qualifying medical bills to the state and the spend down is verified as met, claims will be denied under this code.

How to Resolve

1. Verify the spend down amount Confirm the remaining spend down amount with the state Medicaid agency.
2. Communicate with the patient Explain the spend down requirement and the amount they owe for services before the threshold was met.
3. Collect from the patient Send a statement and follow your collection workflow. The patient's payment may itself count toward the spend down.
4. Assist with future spend down tracking Help the patient understand how to submit qualifying expenses to the state going forward.

How to Prevent PR-178

• Inform patients about their spend down status before scheduling services
• Collect estimated patient responsibility at the time of service when the spend down has not been met

Also Filed As

The same CARC 178 may appear with different Group Codes:

Related Denial Codes