PR-183: Referring Provider Not Eligible to Refer

What Does PR-183 Mean?

With PR (Patient Responsibility), the patient is financially responsible because the referral was made by an ineligible provider. This is unusual for a referring provider issue and may indicate the patient obtained a referral from an out-of-network or non-enrolled provider.

CARC 183 indicates that the referring provider listed on the claim does not meet the payer's requirements for making referrals. This could mean the referring provider is not enrolled with the payer, their NPI is invalid or inactive, their specialty is not authorized to make referrals for the billed service, or they have been excluded from federal healthcare programs.

This code is common for services that require a physician referral, such as specialist consultations, physical therapy, and certain diagnostic tests. The payer validates the referring provider's status during claim processing and rejects the claim if the referral source is not eligible. Resolving this requires verifying and correcting the referring provider's information.

How to Resolve

1. Verify the referral provider's status Determine why the referring provider is ineligible.
2. Obtain a valid referral if possible If a valid referral can be obtained retroactively, do so and request reprocessing.
3. Collect from the patient if PR is confirmed If the referral issue cannot be resolved, communicate the charges to the patient.

How to Prevent PR-183

• Verify referral provider eligibility before scheduling services
• Inform patients about the importance of obtaining referrals from in-network, enrolled providers

Also Filed As

The same CARC 183 may appear with different Group Codes:

Related Denial Codes