PR-297: Medical Plan Benefits Not Available - Submit to Vision

What Does PR-297 Mean?

When paired with Group Code PR, CARC 297 shifts the financial responsibility to the patient. The adjustment for medical plan benefits not available - submit to vision is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.

CARC 297 indicates the medical plan received the claim, determined that benefits are not available under the medical benefit, and is directing the provider to submit the claim to the patient's vision plan instead. Unlike CARC 298 (which indicates the medical plan forwarded the claim automatically), CARC 297 places the resubmission responsibility on the provider.

This code appears for vision-related services such as routine eye exams, refractions, contact lens fittings, and eyewear that were billed to the medical plan. Many patients have separate vision insurance through carriers like VSP, EyeMed, or Davis Vision, and the medical plan does not cover services that fall within the vision benefit scope. The medical plan is telling you that the service is not their responsibility and directing you to the correct payer.

The critical action item with CARC 297 is that you must actively resubmit the claim to the vision plan. The medical plan has not forwarded it on your behalf. If you do not resubmit, the claim will remain unpaid. You need the patient's vision plan information including the payer ID, group number, and member ID to submit correctly. Some services, such as medical eye conditions like glaucoma or diabetic retinal exams, may be covered under the medical plan if billed with the appropriate medical diagnosis codes.

How to Resolve

1. Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 297 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-297

• Verify patient coverage and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively
• Review PR-297 adjustments before billing to confirm the designation is appropriate

Also Filed As

The same CARC 297 may appear with different Group Codes:

Related Denial Codes