CARC 61 Active

PR-61: Failure to Obtain Second Surgical Opinion

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-61 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 61 is owed by the patient. The payer determined that this portion — related to failure to obtain second surgical opinion — falls under the patient's financial obligation per their plan benefits.

CARC 61 relates to failure to obtain second surgical opinion. 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 patient's plan requires a second surgical opinion before certain procedures and it was not obtained; A second opinion was obtained but documentation was not submitted with the claim; Specific payers or plan types mandate a second opinion for elective surgeries. The group code paired with CARC 61 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 did not seek second opinion Patient proceeded with surgery without obtaining the required second opinion, shifting responsibility 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 if the second opinion was obtained or was not required. Bill patient only if the requirement legitimately applies and was not met.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-61:

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

How to Prevent PR-61

Also Filed As

The same CARC 61 may appear with different Group Codes:

CO-61 OA-61

Related Denial Codes

PR-95 — Plan Procedures Not Followed PR-1 — Deductible Amount PR-2 — Coinsurance Amount PR-3 — Co-payment Amount PR-4 — Procedure Code Inconsistent with Modifier

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.