PR-288: Referral Absent

What Does PR-288 Mean?

When paired with Group Code PR, CARC 288 shifts the financial responsibility to the patient. The adjustment for referral absent is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.

When CARC 288 appears on your remittance advice, the payer is telling you that the services billed required a referral from another physician, and that referral was either never obtained or was not included with the claim submission. Many managed care and HMO plans mandate that patients receive a referral from their primary care physician before seeing a specialist or receiving certain services. Without this referral on file, the payer will not process the claim.

This denial is distinct from a prior authorization denial. A referral is a recommendation from a PCP directing the patient to a specialist, while prior authorization is the payer's advance approval for a specific service. Some plans require both. CARC 288 specifically addresses the absence of the referral component. The denial may also trigger if the referral that was submitted has expired, was issued for the wrong provider, or contained incomplete information such as missing diagnosis codes or an unsigned form.

In most cases, CARC 288 appears with a CO group code, placing the financial responsibility on the provider. This is because obtaining and verifying the referral is considered part of the provider's administrative obligations before rendering services. The good news is that this denial is almost always recoverable if the referral can be obtained retroactively and the claim resubmitted within the payer's timely filing window.

How to Resolve

1. Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 288 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-288

• Verify patient coverage and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively
• Review PR-288 adjustments before billing to confirm the designation is appropriate

Also Filed As

The same CARC 288 may appear with different Group Codes:

Related Denial Codes