CARC 49 Active

PR-49: Non-Covered Routine/Preventive Exam

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-49 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 49 is owed by the patient. The payer determined that this portion — related to non-covered routine/preventive exam — falls under the patient's financial obligation per their plan benefits.

CARC 49 indicates non-covered routine/preventive exam. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: the patient's insurance plan does not cover the routine or preventive exam that was billed; A diagnostic or screening procedure performed during a routine exam was denied because it was considered part of the preventive visit; The preventive exam exceeds the plan's allowed frequency (e.g., only one annual wellness visit per year). The group code paired with CARC 49 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 non-covered preventive Patient must pay for preventive services not covered by their plan Most 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 Use the payer portal or eligibility tool to verify the patient's current benefit status and confirm the adjustment aligns with plan terms.
  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

Appeal on patient's behalf if ACA requires coverage of this preventive service.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-49:

RARC Description
N381 Consult contract/fee schedule Review coverage terms before billing patient →

How to Prevent PR-49

Also Filed As

The same CARC 49 may appear with different Group Codes:

CO-49 OA-49

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-35 — Lifetime Benefit Maximum Reached PR-40 — Charges Do Not Meet Emergent/Urgent Care Qualifications PR-51 — Non-Covered Pre-existing Condition PR-55 — Procedure/Treatment Deemed Experimental/Investigational

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.