CARC 50 Active

PR-50: Non-Covered Service - Not Medically Necessary

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-50 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 50 is owed by the patient. The payer determined that this portion — related to non-covered service - not medically necessary — falls under the patient's financial obligation per their plan benefits.

CARC 50 indicates non-covered service - not medically necessary. 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 payer determined the service does not meet their medical necessity guidelines based on the diagnosis, patient history, or clinical evidence; The service does not meet the Local Coverage Determination or National Coverage Determination requirements; The submitted diagnosis code does not support the medical necessity for the procedure or treatment. The group code paired with CARC 50 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
ABN signed by patient Patient signed an Advance Beneficiary Notice (ABN) accepting financial responsibility for potentially non-covered services Most Common
Patient elected to receive non-covered service Patient chose to proceed with the service knowing it may not be covered 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 provider believes the service was medically necessary, appeal on the patient's behalf with clinical documentation. If the appeal succeeds, refund any amounts collected from the patient.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-50:

RARC Description
N115 Based on Local Coverage Determination Review LCD before billing patient →
N386 Based on National Coverage Determination Check NCD criteria →

How to Prevent PR-50

Also Filed As

The same CARC 50 may appear with different Group Codes:

CO-50 OA-50

Related Denial Codes

PR-85 — Patient Interest Adjustment 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

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/50
  3. https://medsolercm.com/blog/co-50-denial-code
  4. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c22pdf.pdf
  5. Codes maintained by X12. Visit x12.org for official definitions.