PR-287: Referral Exceeded

What Does PR-287 Mean?

PR-287 means the patient is financially responsible for services received after the referral limit was exceeded. The patient either continued treatment knowing the referral was exhausted or failed to obtain a new referral from their PCP.

CARC 287 fires when the number of visits or services provided under a referral exceeds the authorized limit. Every referral has boundaries — a maximum number of visits, a date range, or both. Once those limits are reached, any additional services under that referral will be denied.

This denial is common in managed care plans (HMOs and some PPOs) that require referrals from a primary care physician before patients can see specialists. The referral typically authorizes a specific number of visits (e.g., 6 physical therapy sessions) or is valid for a limited time period (e.g., 90 days). When the provider continues treating the patient beyond those limits without obtaining a new or extended referral, CARC 287 results.

The financial impact depends on the Group Code. Under CO, the provider should have tracked the referral and obtained an extension before the limit was reached — they absorb the cost. Under PR, the patient is responsible because they continued scheduling appointments after being informed the referral was exhausted, or they failed to obtain a new referral from their PCP as required by their plan.

Common Causes

How to Resolve

Obtain a new referral or extension from the referring physician, then resubmit the claim with updated referral information.

1. Confirm the referral is exhausted Verify the referral was indeed exceeded and the denial is correct.
2. Notify the patient Inform the patient their referral limit was reached and they are responsible for the cost of additional visits.
3. Help obtain new referral Assist the patient in getting a new referral from their PCP if they wish to continue treatment.
4. Bill the patient Bill the patient for the visits that exceeded the referral limit.

How to Prevent PR-287

• Inform patients about their referral limits and remaining visits at each appointment
• Send notifications when referral visits are running low
• Educate patients on the process for obtaining new referrals from their PCP
• Obtain financial responsibility acknowledgment before providing services without a valid referral

General Prevention

• Inform patients about their referral limits and how many visits remain at each appointment
• Send patient notifications when referral visits are running low
• Obtain financial responsibility acknowledgment from patients before providing services without a valid referral

Also Filed As

The same CARC 287 may appear with different Group Codes:

Related Denial Codes