CARC 303 Active

PR-303: Prior Payer Patient Responsibility Not Covered for QMB

TL;DR

Unusual combination. Verify the patient's QMB status before taking any collection action.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-303 Mean?

PR with CARC 303 is uncommon since QMB patients should not be balance-billed. If this combination appears, verify whether the patient's QMB status is correct.

CARC 303 applies to Qualified Medicare Beneficiaries (QMB) — dual-eligible individuals who have both Medicare and Medicaid coverage. Under federal law, providers are prohibited from billing QMB patients for Medicare cost-sharing amounts such as deductibles, coinsurance, and copayments. When Medicaid (or the state program) does not cover these cost-sharing amounts, the provider must absorb them.

This code appears when the provider attempted to collect or bill the patient's Medicare cost-sharing, or when the coordination between Medicare and Medicaid results in the cost-sharing amount being written off. The provider cannot balance-bill the patient for this amount regardless of whether the state Medicaid program pays the cost-sharing.

How to Resolve

  1. Verify whether the patient is actually a QMB — if so, the PR assignment is likely an error
  2. Contact the payer to clarify the PR assignment for a QMB-related code
  3. If the patient is not QMB, process normally per PR procedures
Do Not Appeal This Code

Prior Payer Patient Responsibility Not Covered for QMB reflects a service that falls outside covered benefits, with the patient held responsible. Coverage decisions per plan terms generally aren't appealable in the traditional sense — the appropriate next step is verifying the patient was informed (ABN where applicable) and billing the patient if the determination is correct.

How to Prevent PR-303

Also Filed As

The same CARC 303 may appear with different Group Codes:

CO-303 OA-303

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/303
  3. https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordination-office
  4. Codes maintained by X12. Visit x12.org for official definitions.