PR-289: Dental and Medical Plans Considered - Benefits Not Available
PR-289: The patient is financially responsible for this amount. Verify the determination is correct before initiating patient billing.
What Does PR-289 Mean?
When paired with Group Code PR, CARC 289 shifts the financial responsibility to the patient. The adjustment for dental and medical plans considered - benefits not available is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.
When CARC 289 appears on your remittance, the payer is communicating that the services billed have been evaluated under both the dental and medical plan benefit structures, and coverage is not available under either one. This code sits at the intersection of dental-medical coordination and is often triggered when a procedure could theoretically fall under either benefit type but the patient's specific plan design excludes it from both.
This denial frequently surfaces with procedures that straddle the dental-medical boundary, such as certain oral surgery procedures, TMJ treatments, or dental anesthesia services. The payer has determined that the dental plan does not cover the service, and the medical plan also does not provide benefits for it. Unlike CARC 290 or 291 where the claim is forwarded to the other plan, CARC 289 indicates that both avenues have been exhausted.
The financial impact depends heavily on the group code. With CO, the provider absorbs the cost. With OA, the responsibility may fall on the patient or require further investigation. Before writing off the balance, verify that the correct procedure and diagnosis codes were used, as coding adjustments may allow the claim to be reprocessed successfully under one of the plans. Related codes to be aware of include CARC 254, 270, and 280, which address similar cross-plan coverage scenarios.
How to Resolve
- Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 289 adjustment. Review the remittance advice and any RARC codes for context.
- 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.
- 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.
- Generate patient statement If the determination is correct, generate a patient statement for the amount and follow standard patient collection procedures.
- Communicate with the patient Explain the charge to the patient, provide information about their financial responsibility, and discuss payment options.
Dental and Medical Plans Considered - Benefits Not Available grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.
How to Prevent PR-289
- Verify patient coverage and financial responsibility before rendering services
- Communicate potential out-of-pocket costs to patients proactively
- Review PR-289 adjustments before billing to confirm the designation is appropriate
Also Filed As
The same CARC 289 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/289
- https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.