CARC 215 Active

PR-215: Based on Subrogation of a Third Party Settlement

TL;DR

The patient received settlement funds for medical expenses. Collect from the patient.

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-215 Mean?

With PR (Patient Responsibility), the patient is responsible because they received a third-party settlement that includes funds for medical expenses. The patient should use settlement funds to pay the provider.

CARC 215 indicates that the payer's payment was reduced or denied because a third-party settlement (such as an auto insurance settlement, workers compensation settlement, or personal injury settlement) includes funds designated for the medical expenses billed on this claim. The payer is exercising its subrogation rights to recover or reduce payment because the patient has already received compensation for these services from another source.

Subrogation is the legal right of the insurance company to seek reimbursement from a third party that caused the injury or from settlement funds designated for medical costs. This is common in auto accident cases, slip-and-fall injuries, and workers compensation claims where a third party is financially responsible.

How to Resolve

  1. Communicate with the patient Inform the patient that settlement funds should cover these medical expenses.
  2. Collect from the patient Send a statement and coordinate payment from the settlement funds.
Do Not Appeal This Code

Based on Subrogation of a Third Party Settlement grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

How to Prevent PR-215

Also Filed As

The same CARC 215 may appear with different Group Codes:

CO-215 OA-215

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

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.