CARC 55 Active

PR-55: Procedure/Treatment Deemed Experimental/Investigational

TL;DR

Patient responsibility — review the denial and appeal if the patient should not be liable. Do not bill the patient until the appeal is resolved.

Action
Appeal
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-55 Mean?

With PR (Patient Responsibility), the CARC 55 adjustment for procedure/treatment deemed experimental/investigational shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. The most common cause is patient chose to receive experimental treatment knowing it may not be covered — if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

CARC 55 indicates procedure/treatment deemed experimental/investigational. 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's medical policy classifies the procedure, treatment, or drug as experimental or investigational; The payer determined there is insufficient clinical evidence that the treatment is effective for the patient's condition; Drug or device is used off-label for an indication not approved by the FDA. The group code paired with CARC 55 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 elected experimental treatment Patient chose to receive experimental treatment knowing it may not be covered Most Common

How to Resolve

  1. Review the denial Examine the PR-55 denial and any RARC codes to understand why the patient was held responsible.
  2. Gather supporting documentation Collect medical records, authorization documents, or plan benefit details that support coverage.
  3. File an appeal Appeal on the patient's behalf with clinical evidence. If the appeal fails, the patient is responsible for the charges.
  4. Hold patient billing pending appeal Do not bill the patient until the appeal is resolved. If the appeal is denied, then generate a patient statement.
Appeal Guide

Appeal on the patient's behalf with clinical evidence. If the appeal fails, the patient is responsible for the charges.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-55:

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

How to Prevent PR-55

Also Filed As

The same CARC 55 may appear with different Group Codes:

CO-55 OA-55

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-49 — Non-Covered Routine/Preventive Exam PR-51 — Non-Covered Pre-existing Condition

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/55
  3. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  4. Codes maintained by X12. Visit x12.org for official definitions.