PR-193: Original Payment Decision Maintained

What Does PR-193 Mean?

PR-193 indicates the payer has reviewed a challenge to a patient responsibility determination and confirmed that the patient owes the originally assessed amount. This typically follows a dispute about deductible application, coinsurance calculation, copay amount, or a non-covered service classification. The payer stands by its original position that the charges are the patient's financial obligation.

When CARC 193 shows up on a remittance, the payer is telling you that a reconsideration, redetermination, or appeal has been completed and the original payment decision stands. This is not a new denial — it is the payer's confirmation that the previous adjustment or denial was reviewed and found to be correct. You will typically see this code after submitting an appeal, requesting a reconsideration, or disputing a prior claim adjudication.

The significance of CARC 193 depends heavily on the group code. Under CO, the payer is maintaining a contractual adjustment — perhaps a fee schedule reduction, a bundling edit, or a coverage exclusion — and the provider must absorb the write-off unless a higher-level appeal is pursued. Under PR, the payer is reaffirming that the patient owes a specific amount (deductible, coinsurance, or non-covered charge) after the provider or patient challenged that determination. In both cases, the original rationale for the adjustment remains unchanged.

Receiving CARC 193 does not necessarily mean the case is closed. Most payer appeal processes have multiple levels, and you may still have the option to escalate. For Medicare, the progression runs from redetermination to reconsideration by a QIC, then to an ALJ hearing and beyond. For commercial payers, check the contract for the number of appeal levels available. The key question is whether you have new clinical documentation, corrected coding, or a different legal argument that was not presented in the initial challenge.

Common Causes

How to Resolve

Determine whether the upheld decision is correct, and if not, escalate to the next available appeal level with new supporting evidence.

1. Verify the patient responsibility calculation Cross-check the patient's benefits, deductible status, and coinsurance rates against the amount the payer is maintaining as patient responsibility. Confirm the math is correct.
2. Transfer balance to the patient account If the determination is correct, move the balance from insurance A/R to the patient responsibility ledger and generate a statement that clearly explains why the patient owes this amount.
3. Escalate if the determination appears incorrect If your review reveals the patient responsibility was miscalculated (e.g., deductible was already met based on other claims), file a higher-level appeal with documentation proving the error.
4. Collect from the patient Enter the confirmed balance into your patient collections workflow. Provide the patient with a clear explanation and offer payment plan options for larger amounts.

How to Prevent PR-193

• Verify patient benefits and cost-sharing amounts before services are rendered to set accurate financial expectations upfront
• Communicate patient responsibility amounts clearly at registration and at the time of service to minimize post-adjudication disputes
• Keep records of patient financial counseling conversations to support the original determination if challenged

General Prevention

• Verify patient benefits and cost-sharing obligations before services are rendered to set accurate financial expectations
• Communicate patient responsibility amounts clearly at the time of service to reduce disputes
• Document patient financial counseling and benefit explanations to support the original determination if challenged

Also Filed As

The same CARC 193 may appear with different Group Codes:

Related Denial Codes