CARC 279 Active

PR-279: Services Not Provided by Preferred Network Providers

TL;DR

The patient used a non-preferred provider and owes the cost difference. Inform them of their responsibility and bill accordingly.

Action

Collect from Patient

Who Pays

Patient

Appeal

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-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.

Common Causes

Cause	Frequency
Patient used out-of-network provider The patient received services from a provider who is not part of their plan's preferred network, and the patient is responsible for the higher out-of-network cost or the full charge	Most Common
Missing referral for specialist services The patient's plan requires a referral from their PCP to see a preferred network specialist, but no referral was obtained	Common
Missing prior authorization for out-of-network care The patient did not obtain required prior authorization before receiving services from a non-preferred provider	Common

How to Resolve

Verify the provider's network tier status, check for exceptions or authorizations, and either resolve the network classification or bill the patient for out-of-network costs.

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

Do Not Appeal This Code

PR-279 indicates the patient chose to use a non-preferred network provider and is financially responsible. Bill the patient for the denied amount. If there were extenuating circumstances (emergency, no preferred provider available), contact the payer to discuss reclassification.

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

General Prevention

Inform patients about their plan's preferred network requirements before providing services
Help patients verify whether the provider is in their preferred network tier
Obtain required referrals before rendering specialist services
Collect estimated out-of-network costs from patients upfront when preferred network providers are not used

Also Filed As

The same CARC 279 may appear with different Group Codes:

CO-279

Related Denial Codes

PR-1 — Deductible Amount PR-2 — Coinsurance Amount PR-3 — Co-payment Amount PR-49 — Routine/Preventive Exam Not Covered PR-50 — Non-Covered Services / Medical Necessity Denial

Sources

https://www.mdclarity.com/denial-code/279
https://x12.org/codes/claim-adjustment-reason-codes
Codes maintained by X12. Visit x12.org for official definitions.