PR-272: Coverage/Program Guidelines Not Met

What Does PR-272 Mean?

PR-272 shifts the financial responsibility to the patient. The payer determined the service does not meet coverage guidelines, and the charge is the patient's direct obligation. This typically occurs when the service is excluded from the plan or when the patient received a non-covered benefit.

When CARC 272 appears on a remittance, the payer is telling you that the billed service failed to satisfy one or more of their coverage or program guidelines. Unlike CARC 273 (guidelines exceeded), CARC 272 indicates that a minimum threshold or requirement was not reached. The service may have been denied because prior authorization was not obtained, medical necessity criteria were not documented, required clinical prerequisites were not completed, or the service simply is not covered under the patient's plan.

This is one of the broader denial codes in the CARC system, covering a wide range of guideline failures. The payer may pair it with a RARC that provides more specific detail about which guideline was not met. Always check the accompanying remark codes and the 835 Healthcare Policy Identification Segment for the precise policy reference. Without this detail, determining the correct resolution path is difficult because "guidelines not met" could mean anything from a missing modifier to a fundamentally non-covered service.

The group code determines the financial impact. Under CO, the provider absorbs the cost as a contractual write-off unless an appeal succeeds. Under PR, the patient is responsible for the charge. CARC 272 denials under CO are frequently appealable — especially when the guideline was technically met but the documentation submitted with the original claim was insufficient to demonstrate compliance. Gathering and submitting the missing documentation often resolves the denial without a formal appeal.

Common Causes

How to Resolve

Identify which specific coverage guideline was not met, correct any coding or documentation deficiencies, and appeal with supporting evidence or resubmit the corrected claim.

1. Confirm the coverage exclusion Verify with the payer that the service is genuinely excluded from the patient's plan under the cited guideline.
2. Transfer the charge to the patient Move the denied amount to the patient's account and generate a statement explaining the charge.
3. Contact the patient Inform the patient that the service is not covered under their plan guidelines, explain the amount owed, and offer payment options.

How to Prevent PR-272

• Verify coverage for the planned service before rendering it and inform the patient of potential out-of-pocket costs
• Obtain signed financial consent from patients when coverage for a service is uncertain
• Run eligibility verification to check program guidelines before scheduling services

General Prevention

• Verify patient eligibility and coverage guidelines for the planned service before rendering it
• Obtain required prior authorizations proactively before performing the service
• Maintain detailed and accurate clinical documentation that addresses the payer's medical necessity criteria
• Stay current with payer-specific coverage guidelines and policy updates
• Implement pre-submission claim edits that check for guideline compliance before the claim is sent
• Conduct staff training on payer coverage requirements and documentation standards

Also Filed As

The same CARC 272 may appear with different Group Codes:

Related Denial Codes