CARC 277 Active

PR-277: Claim Undetermined During SHOP Exchange Grace Period

TL;DR

The SHOP grace period ended and the patient's coverage was terminated. The patient owes the charges — send a patient statement for services rendered during the uncovered period.

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-277 Mean?

PR-277 may appear when the grace period has concluded and coverage was terminated due to non-payment of premiums, shifting the financial responsibility to the patient. This signals that the temporary hold has been resolved with a determination that the patient is liable for the services rendered during the uncovered period.

CARC 277 is specifically designed for claims involving patients enrolled through the Health Insurance SHOP (Small Business Health Options Program) Exchange. It fires when the payer cannot finalize the claim's disposition because the employer or employee has not yet paid the insurance premium within the 31-day grace period.

This code is distinct from CARC 257, which covers individual Marketplace plans with a 90-day grace period. CARC 277 applies exclusively to SHOP Exchange plans, which have a shorter 31-day grace period because the coverage is employer-sponsored through the small business exchange.

The claim is not permanently denied — it is temporarily undetermined. Once the grace period concludes, the payer will either reprocess and pay the claim (if the premium was paid) or deny it permanently (if coverage was terminated due to non-payment). The primary Group Code is OA, reflecting the temporary and informational nature of the adjustment.

How to Resolve

  1. Confirm coverage termination Verify with the payer that the patient's SHOP Exchange coverage has been terminated due to non-payment of premiums.
  2. Check for reinstatement Determine whether the patient or their employer has reinstated coverage or enrolled in a new plan that might cover the services retroactively.
  3. Bill the patient If coverage is confirmed terminated, send a patient statement for services rendered during the uncovered period.
  4. Offer payment arrangements Work with the patient on payment arrangements if the balance is significant, as patients who lost employer-sponsored coverage may face financial challenges.
Do Not Appeal This Code

Claim Undetermined During SHOP Exchange Grace Period 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.

How to Prevent PR-277

Also Filed As

The same CARC 277 may appear with different Group Codes:

OA-277 CO-277

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/277
  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.