PR-285: Appeal Procedures Not Followed

What Does PR-285 Mean?

When paired with Group Code PR, CARC 285 shifts the financial responsibility to the patient. The adjustment for appeal procedures not followed is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.

CARC 285 is a procedural rejection of an appeal — not a decision on the appeal's merits. The payer is saying your appeal was not considered because it did not follow their required submission procedures. The underlying claim denial has not been reviewed on substance.

This is a frustrating but fixable denial. Common procedural failures include submitting the appeal through the wrong channel (mail vs. electronic), using the wrong forms, omitting required supporting documentation, skipping a required level of appeal (e.g., going directly to second-level review without completing first-level), or not addressing the appeal to the correct department. Each payer has specific appeal procedures, and what works for one payer may not work for another.

The critical point is that your appeal window may still be open — CARC 285 does not necessarily mean you have lost the right to appeal. However, the clock is ticking. Review the denial letter immediately, obtain the payer's complete appeal procedure documentation, and resubmit a properly formatted appeal within the remaining timeframe. If the appeal deadline has passed due to the procedural rejection, request an extension citing the circumstances.

How to Resolve

1. Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 285 adjustment. Review the remittance advice and any RARC codes for context.
2. Review for potential errors Check whether the underlying denial reason can be corrected, which may eliminate the patient's responsibility. Verify coding accuracy and documentation completeness.
3. Appeal if designation is incorrect If the PR assignment appears incorrect or the denial is in error, file an appeal with supporting documentation before billing the patient.
4. Generate patient statement If the determination is correct, generate a patient statement for the amount and follow standard patient collection procedures.
5. Communicate with the patient Explain the charge to the patient, provide information about their financial responsibility, and discuss payment options.

How to Prevent PR-285

• Verify patient coverage and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively
• Review PR-285 adjustments before billing to confirm the designation is appropriate

Also Filed As

The same CARC 285 may appear with different Group Codes:

Related Denial Codes