PR-238: Claim Spans Eligible/Ineligible Periods - Ineligible Reduction
The patient owes for the ineligible portion. Collect for the dates outside their coverage period.
What Does PR-238 Mean?
With PR, the patient is responsible for the ineligible portion of the claim. This is the standard group code when the patient's coverage did not cover part of the service period.
CARC 238 indicates that the claim covers a date range that includes both dates when the patient was eligible for coverage and dates when they were not. The payer reduced the payment to cover only the eligible portion and excluded the ineligible dates. This commonly occurs with inpatient stays or ongoing service episodes where the patient's coverage started or ended during the service period.
For example, if a patient was admitted on January 15 but their coverage did not begin until January 20, the payer would reduce payment to cover only January 20 onward. The provider may need to bill the patient separately for the ineligible dates.
Common Causes
| Cause | Frequency |
|---|---|
| Inpatient stay spans coverage eligibility change The patient's hospital stay or service period spans a date when their insurance coverage changed or ended, and the portion during the ineligible period is the patient's responsibility | Most Common |
| Coverage terminated during treatment period The patient's insurance coverage ended during the treatment period and the remaining days are assigned to the patient | Common |
| New coverage effective date falls within service period The patient's new insurance coverage started during a service period, and days before the effective date are the patient's responsibility | Common |
| Medicaid eligibility gap during service span The patient's Medicaid eligibility had a gap during the service period and the ineligible days are assigned to patient responsibility | Occasional |
How to Resolve
- Verify eligibility dates Confirm which dates were ineligible.
- Communicate with the patient Inform the patient of the charges for the ineligible period.
- Collect from the patient Send a statement for the ineligible portion.
Appeal if the patient had active coverage during the period marked as ineligible. Include proof of coverage (insurance card, eligibility verification, retroactive enrollment documentation) showing the patient was covered during the denied period.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-238:
| RARC | Description |
|---|---|
| N130 | Consult plan benefit documents/guidelines for coverage of this service. Review the patient's coverage dates and benefit documents to verify the eligible and ineligible periods → |
How to Prevent PR-238
- Verify patient eligibility dates before admission or service initiation
- Track coverage start and end dates for ongoing service episodes
General Prevention
- Verify patient insurance eligibility and coverage dates at every visit, especially for inpatient admissions
- Monitor coverage changes during long inpatient stays
- Check for coverage gaps when patients are transitioning between insurance plans
- Inform patients about potential gaps in coverage and their financial responsibility
Also Filed As
The same CARC 238 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- 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
- https://www.aapc.com/resources/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.