PR-273: Coverage/Program Guidelines Exceeded

What Does PR-273 Mean?

PR-273 shifts the excess coverage amount to the patient. The patient has exhausted their covered benefits for this service type, and any additional charges are their direct financial responsibility. The provider should bill the patient for the amount shown on the remittance.

When CARC 273 appears on a remittance, the payer is indicating that the billed service went beyond the limits established in the patient's coverage or program guidelines. Unlike CARC 272 (guidelines not met), CARC 273 specifically signals that a maximum was reached or surpassed. The service itself may be covered in principle, but the patient has exhausted their available benefits for that service type — whether measured in visit counts, units, dollar amounts, or time periods.

This denial is common in rehabilitation services (physical therapy, occupational therapy, speech therapy), behavioral health, chiropractic care, and any specialty where payers impose visit limits or benefit caps. For example, a plan may cover 20 physical therapy visits per calendar year — visit 21 triggers CARC 273. Similarly, a plan may limit the number of units of a specific drug or supply, and billing beyond that cap results in this adjustment.

The group code is critical for determining your next step. Under CO, the excess amount is a contractual write-off that the provider absorbs. Under PR, the patient is responsible for the overage. In both cases, there may be an opportunity to appeal if the additional services were medically necessary. Many payers have exception processes where a provider can request additional visits or units beyond the standard cap by submitting clinical documentation demonstrating ongoing medical need. The key is to request these exceptions proactively — ideally before the patient reaches the benefit limit — rather than retroactively after a denial.

Common Causes

How to Resolve

Verify the benefit limit that was exceeded, confirm coding accuracy, and appeal with medical necessity documentation if the additional services were clinically required.

1. Verify the patient's benefit exhaustion Confirm with the payer that the patient has reached their maximum covered benefits for this service type.
2. Transfer the excess charge to the patient Move the PR-273 amount to the patient's account and generate a statement showing the service date, procedure, and amount owed.
3. Contact the patient about the balance Inform the patient that their covered benefits have been exhausted, explain the remaining charges, and offer payment options or a payment plan.
4. Discuss future treatment costs Let the patient know their benefit status for future services so they can make informed decisions about continuing treatment.

How to Prevent PR-273

• Verify the patient's remaining benefits before each visit and inform them when they are approaching their coverage limit
• Obtain signed financial consent from patients acknowledging they will be responsible for charges once benefits are exhausted
• Provide cost estimates for services that will exceed the patient's remaining covered benefits
• Track benefit utilization in your scheduling system to proactively alert patients before they exceed their limits

General Prevention

• Verify the patient's remaining benefit limits and coverage caps before rendering services
• Obtain prior authorization when approaching plan limits to confirm coverage for additional services
• Track patients' utilization against their plan limits throughout the benefit period
• Maintain clear communication with patients about their remaining covered benefits before scheduling additional services
• Review payer coverage guidelines regularly to stay current with frequency limits, unit caps, and benefit maximums
• Implement billing system alerts that flag when a patient is approaching or has exceeded their coverage limits

Also Filed As

The same CARC 273 may appear with different Group Codes:

Related Denial Codes