CARC 26 Active

PR-26: Expenses Incurred Prior to Coverage

TL;DR

The patient is responsible for this adjustment 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-26 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 26 is owed by the patient. The payer determined that this portion — related to expenses incurred prior to coverage — falls under the patient's financial obligation per their plan benefits.

CARC 26 indicates expenses incurred prior to coverage. 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: the date of service on the claim is before the patient's insurance coverage began; The patient's coverage was retroactively terminated to a date before the service; The payer has an incorrect coverage start date in their system. The group code paired with CARC 26 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 not yet covered Patient received services before their insurance was effective, making them responsible Most Common

How to Resolve

  1. Verify the adjusted amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the adjustment amount was applied correctly per plan terms.
  2. Confirm plan benefit details Use the payer portal or eligibility tool to verify the patient's current benefit status and confirm the adjustment aligns with plan terms.
  3. Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the adjustment 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

If the patient was genuinely not covered on the date of service, the expense is the patient's responsibility. No appeal is warranted for legitimate pre-coverage services.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-26:

RARC Description
N30 Patient not eligible on date of service Verify coverage date and bill patient if confirmed →
N381 Consult contract/fee schedule for payment information Review patient's coverage terms →

How to Prevent PR-26

Also Filed As

The same CARC 26 may appear with different Group Codes:

CO-26 OA-26

Related Denial Codes

PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns PR-35 — Lifetime Benefit Maximum Reached

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.