PR-186: Level of Care Change Adjustment

What Does PR-186 Mean?

With PR (Patient Responsibility), the level-of-care difference has been assigned to the patient. This may occur when the patient requested or continued a higher level of care against the payer's determination. The patient is responsible for the cost difference between the billed and approved levels.

CARC 186 appears when the payer downgrades the level of care on a claim after reviewing the clinical documentation. Rather than paying at the billed level (such as inpatient, ICU, or skilled nursing), the payer determined a lower level was medically appropriate — for example, observation instead of inpatient, step-down instead of ICU, or home health instead of skilled nursing.

This is a partial payment adjustment, not a full denial. The payer pays at the reduced level of care and denies the difference. Level-of-care downgrades are among the most impactful adjustments for hospitals and facilities because the payment difference between levels can be substantial. The most effective response is a clinical appeal with documentation supporting the billed level of care.

How to Resolve

1. Verify the PR assignment Confirm the payer correctly assigned the level-of-care difference to the patient.
2. Communicate with the patient Explain the level-of-care determination and the resulting financial responsibility.
3. Collect from the patient Send a statement and follow your collection process. Offer payment plan options for large balances.

How to Prevent PR-186

• Inform patients when a level-of-care change is recommended by the payer
• Document patient consent if they choose to remain at a higher level of care against the payer's determination

Also Filed As

The same CARC 186 may appear with different Group Codes:

Related Denial Codes