CARC 213 Active

PR-213: Non-Compliance with Physician Self-Referral Prohibition

TL;DR

Patient charges for a self-referral issue are unusual. Review the compliance issue first.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-213 Mean?

With PR (Patient Responsibility), the patient may be assigned the cost of a service that violates self-referral rules. This is unusual — Stark Law issues are typically provider compliance matters.

CARC 213 indicates that the payer determined the claim may involve a violation of the physician self-referral prohibition, commonly known as the Stark Law. This federal law prohibits physicians from referring Medicare and Medicaid patients for designated health services to entities with which they or their immediate family members have a financial relationship, unless a specific exception applies.

Designated health services under Stark include clinical laboratory services, radiology, physical therapy, DME, and several others. If a financial relationship exists between the referring physician and the service provider, and no exception applies, the claim cannot be paid.

How to Resolve

  1. Resolve the compliance issue Address the Stark Law concern before billing the patient.
  2. Collect if PR is confirmed If the payer confirms patient responsibility, communicate the charges.
Do Not Appeal This Code

Non-Compliance with Physician Self-Referral Prohibition reflects an authorization or referral issue. The standard path is not an appeal but a request for retroactive authorization through the payer's process — appeals only apply when authorization was obtained but the payer failed to record it. Gather the authorization documentation if available; otherwise the adjustment usually stands.

How to Prevent PR-213

Also Filed As

The same CARC 213 may appear with different Group Codes:

CO-213 OA-213

Related Denial Codes

PR-39 — Services Denied at Authorization/Pre-certification PR-61 — Failure to Obtain Second Surgical Opinion PR-95 — Plan Procedures Not Followed PR-197 — Precertification/Authorization/Notification Absent PR-198 — Precertification/Authorization Limits Exceeded

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  3. https://www.aapc.com/resources/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.