CARC 23 Active

PR-23: Prior Payer Adjudication Impact

TL;DR

The patient owes this prior payer adjudication impact amount. Verify the balance and 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-23 Mean?

With PR (Patient Responsibility), the prior payer adjudication impact is the patient's financial obligation. The insurer processed the claim, applied the patient's plan benefits, and this amount is owed directly by the patient. The most common scenario is primary payer assigned patient responsibility that the secondary payer does not cover.

CARC 23 indicates prior payer adjudication impact. 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: secondary payer applies its own fee schedule or contractual adjustments after the primary payer's payment; Primary payer's payment exceeded the secondary payer's allowable, resulting in no additional payment; Adjustments from the primary payer are applied to the secondary claim processing. The group code paired with CARC 23 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

Cause Frequency
Patient responsibility from prior payer Primary payer assigned patient responsibility that the secondary payer does not cover Most Common
COB patient balance After both payers process, remaining balance is patient responsibility Common

How to Resolve

  1. Verify the prior payer adjudication impact amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the prior payer adjudication impact amount was applied correctly per plan terms.
  2. Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
  3. Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the prior payer adjudication impact amount, and the balance the patient owes.
  4. Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
  5. Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
Do Not Appeal This Code

The patient responsibility amount reflects the balance remaining after both payers have processed the claim per COB rules. This is the correct patient obligation unless the COB calculation itself contains an error.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-23:

RARC Description
N381 Consult contract/fee schedule for payment information Review both payer fee schedules to verify patient balance →

How to Prevent PR-23

Also Filed As

The same CARC 23 may appear with different Group Codes:

CO-23 OA-23

Related Denial Codes

PR-1 — Deductible Amount PR-2 — Coinsurance Amount PR-3 — Co-payment Amount PR-66 — Blood Deductible PR-78 — Non-Covered Days / Room Charge Adjustment

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.