PR-279: Services Not Provided by Preferred Network Providers

What Does PR-279 Mean?

PR-279 means the patient chose to receive services from a non-preferred provider and is financially responsible for the additional cost. The patient may owe the difference between preferred and non-preferred rates, or the full charge if the service is not covered out-of-network.

CARC 279 indicates that the services billed were rendered by a provider who is not part of the patient's preferred or narrow network tier. This is distinct from a simple out-of-network denial — it specifically targets plans with multiple network tiers where the provider may be contracted with the payer but is not in the patient's specific preferred tier.

The financial impact depends on the Group Code. Under CO, the provider absorbs the cost difference because they are not in the preferred tier — this is common with tiered network plans where contracted providers receive different reimbursement levels. Under PR, the patient is responsible because they chose to receive services from a non-preferred provider, and the cost difference or full charge is their obligation.

This code has become more common as payers expand tiered network designs and narrow network products. A provider who was previously in a broad network may find themselves outside a patient's narrow or preferred tier, triggering this denial even though they still have a contract with the payer.

How to Resolve

1. Confirm the denial Verify the provider is not in the patient's preferred network and the patient is responsible for the cost.
2. Check for referrals or authorizations Determine if the patient has a referral or prior authorization that may allow coverage at the preferred rate.
3. Communicate with the patient Inform the patient about their financial responsibility for using a non-preferred provider.
4. Bill the patient Bill the patient for the denied amount as they are responsible for out-of-network costs.

How to Prevent PR-279

• Inform patients about their plan's preferred network requirements before services are provided
• Help patients verify whether your practice is in their preferred network tier
• Collect estimated out-of-network costs from patients upfront when preferred tier status is uncertain
• Obtain referrals before rendering specialist services for plans that require them

Also Filed As

The same CARC 279 may appear with different Group Codes:

Related Denial Codes