PR-195: Refund to Erroneous Priority Payer

What Does PR-195 Mean?

With PR (Patient Responsibility), the payer priority correction may have resulted in a patient responsibility amount. This could occur if the correct primary payer applies different patient responsibility amounts than the original payer. Verify the COB adjustments and communicate any changes to the patient.

CARC 195 appears when a coordination of benefits error is corrected. The claim was initially processed and paid by the wrong payer in the priority sequence — for example, Medicare paid as primary when another payer should have been primary, or the secondary payer was treated as the primary. This code reflects the adjustment made to correct the payment order.

This is common in Medicare Secondary Payer (MSP) situations where Medicare was incorrectly billed as the primary payer when another insurer (employer group health plan, auto insurance, workers compensation, etc.) should have paid first. It also occurs when retroactive coverage changes alter the payer priority order.

How to Resolve

1. Verify the patient responsibility amount Review the corrected COB determination to confirm the patient's financial responsibility.
2. Communicate with the patient Explain the COB correction and any changes to their financial responsibility.
3. Collect from the patient Send an updated statement reflecting the corrected amounts.

How to Prevent PR-195

• Verify COB order before services to give patients accurate cost estimates
• Keep patients informed of any insurance priority changes that may affect their costs

Also Filed As

The same CARC 195 may appear with different Group Codes:

Related Denial Codes