PR-69: Day Outlier Amount

What Does PR-69 Mean?

With PR (Patient Responsibility), the CARC 69 adjustment for day outlier amount shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

CARC 69 means the payer adjusted the payment based on day outlier amount. The reimbursement was calculated using the payer's fee schedule, contracted rate, or regulatory payment methodology rather than the billed charge.

Common scenarios that trigger this adjustment include: the inpatient length of stay exceeds the expected days for the DRG, triggering a day outlier payment calculation; The payer applies a day outlier payment methodology for extended inpatient stays; A per diem rate is applied for days beyond the DRG geometric mean length of stay. The group code paired with CARC 69 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

How to Resolve

1. Review the adjustment Examine the PR-69 adjustment and any RARC codes to understand the basis for the patient responsibility.
2. Verify the adjustment is correct Confirm the PR designation and amount are appropriate based on the patient's plan benefits.
3. Appeal if incorrect If the adjustment appears incorrect, file an appeal with supporting documentation.
4. Collect from the patient if valid If the adjustment is confirmed correct, generate a patient statement and follow standard collection procedures.

How to Prevent PR-69

• Verify patient benefits and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively

Also Filed As

The same CARC 69 may appear with different Group Codes:

Related Denial Codes