PR-292: Medical Plan Benefits Not Available - Forwarded to Pharmacy

What Does PR-292 Mean?

When paired with Group Code PR, CARC 292 shifts the financial responsibility to the patient. The adjustment for medical plan benefits not available - forwarded to pharmacy is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.

CARC 292 indicates the medical plan received the claim, determined the service falls under the pharmacy benefit rather than the medical benefit, and has forwarded the claim to the patient's pharmacy plan for processing. This is a routing code that signals the claim is being redirected, not permanently denied.

This code most commonly appears for injectable or infusible medications, specialty drugs, and certain pharmacy-related services that some plans manage through a pharmacy benefit manager (PBM) rather than through the medical benefit. The split between medical and pharmacy benefits varies significantly by payer and plan design. Some plans cover certain drugs under the medical benefit when administered in a provider's office, while others route all drug claims through the pharmacy benefit regardless of setting.

The distinction between CARC 292 and CARC 280 is important: CARC 292 confirms the claim was forwarded to the pharmacy plan, while CARC 280 indicates the medical plan denied the claim without forwarding it. Providers should track the forwarded claim with the pharmacy plan to ensure it does not fall through the cracks during the routing process.

How to Resolve

1. Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 292 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-292

• Verify patient coverage and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively
• Review PR-292 adjustments before billing to confirm the designation is appropriate

Also Filed As

The same CARC 292 may appear with different Group Codes:

Related Denial Codes