PR-275: Prior Payer Patient Responsibility Not Covered
The secondary payer will not cover what the primary left as your patient's responsibility. Verify COB data is correct, then bill the patient.
What Does PR-275 Mean?
PR-275 means the patient is financially responsible for the amount the prior payer left as their obligation. The secondary payer has determined this patient responsibility is not covered under their plan. The patient owes the deductible, coinsurance, or copayment that the primary payer applied.
CARC 275 appears in multi-payer scenarios — typically when a secondary or tertiary payer processes a claim and determines that the patient responsibility amount left by the prior payer is not covered under their plan. The patient's deductible, coinsurance, or copayment from the primary payer remains the patient's obligation.
This code is exclusively used with Group Code PR, making it clear that the patient bears the financial responsibility. It most commonly surfaces on claims where the primary payer has already adjudicated and left a balance that the patient expected the secondary plan to pick up. In practice, many patients with dual coverage assume the secondary payer will cover whatever the primary did not, but that is not always the case.
Before billing the patient, verify that the coordination of benefits information is accurate across both payers. Incorrect patient demographics or COB data can cause the secondary payer to inappropriately deny coverage of the patient responsibility amount.
Common Causes
| Cause | Frequency |
|---|---|
| Secondary payer does not cover prior payer's patient responsibility amounts The current (secondary) payer does not cover the deductible, coinsurance, or copayment amounts that were designated as patient responsibility by the prior (primary) payer | Most Common |
| Coordination of benefits determination Under COB rules, the secondary payer determines that the patient responsibility amounts from the primary payer remain the patient's obligation | Common |
| Prior payer denied the claim entirely The primary payer denied the claim and the secondary payer also does not cover the patient responsibility amounts from that denial | Common |
| Incorrect prior payer information on claim The claim was submitted with incorrect primary payer information causing the secondary payer to incorrectly apply patient responsibility | Occasional |
How to Resolve
- Review prior payer's adjudication Check the primary payer's EOB to see exactly what was applied to deductible, coinsurance, or copayment and confirm the amounts.
- Verify COB with current payer Confirm the coordination of benefits data is correct — wrong demographics or policy information can cause incorrect denials.
- Resubmit if COB errors exist If the patient's information was wrong between payers, correct the data and resubmit to the secondary payer.
- Bill patient for their responsibility If the denial is correct, bill the patient for the deductible, coinsurance, or copayment amount the prior payer left as their obligation.
PR-275 indicates the secondary payer does not cover the patient responsibility amounts (deductible, coinsurance, copay) from the primary payer. This is a standard coordination of benefits determination. The patient is responsible for these amounts. Collect from the patient rather than appealing.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-275:
| RARC | Description |
|---|---|
| N381 | Alert: Consult your contractual agreement for restrictions, billing, and payment information. Review the secondary payer's COB provisions to verify patient responsibility amounts → |
| N479 | Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). Submit the primary payer's EOB to the secondary payer for proper COB adjudication → |
How to Prevent PR-275
- Verify coordination of benefits information with all payers at every visit
- Collect accurate patient demographics and compare against both payers' records
- Educate patients about what their secondary plan does and does not cover regarding primary payer deductibles and coinsurance
- Collect estimated patient responsibility amounts upfront when eligibility checks indicate dual coverage limitations
General Prevention
- Verify insurance eligibility and COB status before rendering services to understand what the secondary payer will cover
- Obtain the primary payer's EOB before filing with the secondary payer
- Educate patients about coverage limitations when they have multiple insurance plans
- Collect patient responsibility amounts at the time of service when possible
- Implement robust claims management processes for multi-payer coordination
Also Filed As
The same CARC 275 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/275
- https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.