PR-19: Workers' Compensation Claim

What Does PR-19 Mean?

With PR (Patient Responsibility), the CARC 19 adjustment for workers' compensation claim 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 19 indicates workers' compensation claim. 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: claim for a work-related injury or illness was submitted to the patient's health insurance instead of the workers' compensation carrier; The payer's system flagged the diagnosis codes as work-related based on injury type or circumstance codes; The health plan determined another carrier (workers' comp) has primary liability for the services. The group code paired with CARC 19 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

How to Resolve

1. Review the adjustment Examine the PR-19 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.

How to Prevent PR-19

• Verify patient benefits and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively

Also Filed As

The same CARC 19 may appear with different Group Codes:

Related Denial Codes