CARC 39 Active

PR-39: Services Denied at Authorization/Pre-certification

TL;DR

The patient is responsible for this adjustment amount. Verify the balance and collect from the patient.

Action
Collect from Patient
Who Pays
Patient
Appeal
Yes
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-39 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 39 is owed by the patient. The payer determined that this portion — related to services denied at authorization/pre-certification — falls under the patient's financial obligation per their plan benefits.

CARC 39 relates to services denied at authorization/pre-certification. The payer requires specific authorization, certification, or referral for this service, and the claim was adjusted because that requirement was not satisfied.

Common scenarios that trigger this adjustment include: the payer denied the authorization request for the service before it was performed; The payer determined the service was not medically necessary during the pre-certification review; The authorization request lacked sufficient clinical information to justify the service. The group code paired with CARC 39 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

Cause Frequency
Patient responsible for unauthorized services Services performed after authorization denial result in patient responsibility Most Common
Patient chose to proceed without authorization Patient elected to receive services despite authorization denial Common

How to Resolve

  1. Verify the adjusted amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the adjustment amount was applied correctly per plan terms.
  2. Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
  3. Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the adjustment amount, and the balance the patient owes.
  4. Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
  5. Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
Appeal Guide

If the authorization denial was based on insufficient information, appeal with additional clinical documentation on the patient's behalf. If the denial stands, the patient is responsible for the charges.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-39:

RARC Description
M62 Missing/incomplete/invalid treatment authorization Review authorization status before billing patient →
N362 Missing/incomplete/invalid prior authorization Check if authorization can still be obtained →

How to Prevent PR-39

Also Filed As

The same CARC 39 may appear with different Group Codes:

CO-39 OA-39

Related Denial Codes

PR-16 — Missing Information or Billing Error PR-61 — Failure to Obtain Second Surgical Opinion PR-95 — Plan Procedures Not Followed PR-197 — Precertification/Authorization/Notification Absent PR-198 — Precertification/Authorization Limits Exceeded

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/39
  3. https://www.patientstudio.com/pr-39-denial
  4. Codes maintained by X12. Visit x12.org for official definitions.