CARC 272 Active

PR-272: Coverage/Program Guidelines Were Not Met

TL;DR

The service did not meet the plan's coverage or program guidelines. Identify which guideline was not met, gather supporting documentation, and appeal with evidence showing the service complies with or qualifies for an exception to the guidelines.

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-272 Mean?

CARC 272 indicates the payer denied the claim because the service did not satisfy the plan's coverage or program guidelines. This is a broad denial code that can encompass many types of guideline non-compliance: missing prior authorization, services not covered under the plan, exceeded benefit limits, insufficient medical necessity documentation, coding errors, or failure to follow plan-specific requirements like referral protocols or step therapy.

The key to resolving this denial is identifying which specific guideline was not met. The accompanying RARC codes may provide clues, but you may also need to review the payer's published program guidelines or contact the payer directly for clarification.

Once you identify the specific guideline issue, you can determine the appropriate resolution — correcting a coding error and resubmitting, obtaining a retroactive authorization, or filing a clinical appeal with documentation showing the service met or should be exempt from the guidelines.

How to Resolve

Identify the specific guideline not met, gather documentation showing compliance, and appeal with evidence.

  1. Review the insurance policy guidelines Examine the patient's plan for specific coverage and program guidelines to understand which requirement was not satisfied.
  2. Verify claim accuracy Check all submitted claim information including procedure codes, diagnosis codes, modifiers, and authorization numbers for accuracy.
  3. Gather supporting documentation Compile comprehensive documentation demonstrating compliance with the guidelines, including medical records, authorization letters, and referral documentation.
  4. Identify missing requirements Determine if any required elements were missing, such as prior authorizations, referrals, or step therapy documentation.
  5. File a formal appeal Submit an appeal with documentation showing the service meets program guidelines, including medical records, authorization documentation, clinical justification, and references to the specific guidelines.
  6. Contact payer for clarification If the specific guideline is unclear, contact the payer representative for clarification on requirements.
  7. Track appeal progress Monitor the appeal and respond promptly to requests for additional information.
Do Not Appeal This Code

Coverage/Program Guidelines Were Not Met 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.

Also Filed As

The same CARC 272 may appear with different Group Codes:

CO-272 OA-272

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/272
  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.