PR-275: Prior Payer's 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 |
|---|---|
| Prior payer did not cover patient's deductible The primary payer processed the claim but left the deductible amount as patient responsibility, and the secondary payer is passing this through as the patient's obligation | Most Common |
| Prior payer's coinsurance not covered by secondary The coinsurance portion left by the primary payer is not covered by the current payer's plan, so the patient remains responsible | Most Common |
| Copayment from prior payer not covered The copayment amount determined by the primary payer is not picked up by the secondary or tertiary payer | Common |
| Coordination of benefits issues Problems with multi-plan coverage coordination result in patient responsibility amounts being passed through rather than covered by subsequent payers | Common |
| Incorrect patient demographic information Errors in patient name, date of birth, or policy number between payers cause the secondary payer to not recognize coverage for the patient responsibility amount | Occasional |
How to Resolve
Verify COB accuracy, confirm the patient responsibility calculation, and bill the patient for their share.
- 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 reflects a legitimate patient responsibility amount that the prior payer's plan left uncovered. Rather than appealing, verify the COB information is correct and bill the patient for their share. If COB data is wrong, correct it and resubmit.
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 patient eligibility and coordination of benefits information with all payers before rendering services
- Collect and verify patient demographic details at every visit to prevent data mismatches between payers
- Educate patients about their coverage details and what their secondary plan does and does not cover
- Collect estimated patient responsibility amounts upfront when possible
- Implement real-time eligibility verification that checks coverage across multiple payers
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/275
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.