PR-21: No-Fault Carrier Responsible

What Does PR-21 Mean?

With PR (Patient Responsibility), the CARC 21 adjustment for no-fault carrier responsible 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 21 indicates no-fault carrier responsible. 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: injury from auto accident in a no-fault insurance state billed to health plan instead of PIP/no-fault carrier; Personal Injury Protection (PIP) benefits have not been exhausted, and the no-fault carrier should pay first; Health plan's system flagged the claim as no-fault based on diagnosis or condition codes. The group code paired with CARC 21 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-21 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-21

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

Also Filed As

The same CARC 21 may appear with different Group Codes:

Related Denial Codes