CARC 257 Active

PR-257: Claim Undetermined During Premium Grace Period (HIX)

TL;DR

The patient's coverage was terminated due to non-payment of premiums and they owe the charges. Send a patient statement for the denied amount.

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-257 Mean?

PR-257 may appear when the grace period has concluded and coverage was retroactively terminated, shifting the financial responsibility to the patient. This is a less common pairing that signals the patient's coverage is no longer active and they are personally responsible for the charges incurred during the uncovered period.

CARC 257 appears when a claim is submitted for a patient enrolled through the Health Insurance Exchange (Marketplace) whose premium payment is overdue. Under ACA regulations, subsidized Marketplace enrollees receive a 90-day grace period before coverage can be terminated for non-payment of premiums.

During the first month of the grace period, payers must process and pay claims normally. During months two and three, however, payers may pend or deny claims with CARC 257, indicating the claim's final disposition depends on whether the patient ultimately pays the overdue premium. This is not a permanent denial — it is a temporary hold.

If the patient pays the premium, claims held under CARC 257 should be automatically reprocessed and paid. If the patient does not pay and coverage is retroactively terminated, the provider must bill the patient directly for services rendered during the retroactive termination period. The primary Group Code is OA, reflecting the temporary and informational nature of the adjustment.

How to Resolve

  1. Confirm coverage termination Verify with the payer that the patient's Marketplace coverage has been retroactively terminated due to non-payment of premiums.
  2. Check for reinstatement Determine whether the patient has reinstated their coverage or enrolled in a new plan that might cover the services retroactively.
  3. Bill the patient If coverage is confirmed terminated, send a patient statement for the services rendered during the uncovered period.
  4. Offer payment arrangements Work with the patient on payment arrangements if the balance is significant, as patients who lost coverage due to non-payment may face financial hardship.
Do Not Appeal This Code

Claim Undetermined During Premium Grace Period (HIX) 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-257

Also Filed As

The same CARC 257 may appear with different Group Codes:

OA-257 CO-257

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://www.mdclarity.com/denial-code/257
  2. https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
  3. https://x12.org/codes/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.