CARC 216 Active

PR-216: Based on Findings of a Review Organization

TL;DR

The patient owes based on the review organization's findings. Inform the patient of their appeal rights.

Action
Collect from Patient
Who Pays
Patient
Appeal
Yes
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-216 Mean?

With PR (Patient Responsibility), the review organization's findings resulted in patient financial responsibility. The patient may appeal through the external review process.

CARC 216 indicates that an external or internal review organization evaluated the claim and determined that the service was not payable as billed. The review organization may have concluded that the service was not medically necessary, was not provided at the appropriate level of care, or did not meet the clinical criteria for coverage.

Review organizations include Quality Improvement Organizations (QIOs) for Medicare, independent review entities for commercial payers, and state-mandated review bodies. Their findings carry significant weight in the appeals process and typically reflect a clinical assessment of the medical records.

Common Causes

Cause Frequency
Review determined patient is responsible for non-covered portion The review organization's findings resulted in a determination that the patient is responsible for the cost of services deemed not medically necessary Common

How to Resolve

  1. Inform the patient Communicate the review findings and the patient's financial responsibility.
  2. Discuss appeal options Advise the patient of their right to appeal the determination.
  3. Collect from the patient If the patient does not appeal, collect the balance.
Appeal Guide

The patient has the right to appeal the review organization's findings. Assist the patient with appeal documentation if requested.

How to Prevent PR-216

General Prevention

Also Filed As

The same CARC 216 may appear with different Group Codes:

CO-216 OA-216

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.