CARC 223 Active

PR-223: Mandated Federal/State/Local Law Adjustment

TL;DR

The patient owes a legally mandated amount. Collect from the patient.

Action
Collect from Patient
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-223 Mean?

With PR (Patient Responsibility), the patient is responsible for a portion mandated by law, such as a state-mandated cost-sharing requirement.

CARC 223 indicates that the payment adjustment was mandated by legislation or regulation rather than by the payer's own policies. This can include adjustments required by the Affordable Care Act, state insurance regulations, Medicaid rate mandates, workers compensation fee schedules set by law, or other legislative requirements that affect healthcare payment.

This code is informational in nature — it tells the provider that the adjustment is not the payer's discretionary decision but rather a compliance requirement with applicable law. The specific law or regulation driving the adjustment may be identified in accompanying remark codes.

Common Causes

Cause Frequency
Law-mandated patient responsibility A federal, state, or local regulation assigns a specific financial responsibility to the patient Common

How to Resolve

  1. Verify the mandated amount Confirm the patient responsibility amount per the applicable law.
  2. Collect from the patient Send a statement and collect.
Do Not Appeal This Code

This adjustment is mandated by federal, state, or local regulation. The patient is responsible for this amount per law. Collect the balance from the patient.

How to Prevent PR-223

General Prevention

Also Filed As

The same CARC 223 may appear with different Group Codes:

CO-223 OA-223

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.