CARC 76 Active

PR-76: Disproportionate Share Adjustment

TL;DR

Patient responsibility — review the adjustment and determine if the patient truly owes this amount.

Action
Review & Decide
Who Pays
Patient
Appeal
No
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-76 Mean?

With PR (Patient Responsibility), the CARC 76 adjustment for disproportionate share adjustment 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 76 means the payer adjusted the payment based on disproportionate share adjustment. 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: hospitals qualifying as disproportionate share hospitals receive an additional payment adjustment under Medicare's Inpatient PPS. CARC 76 reflects the difference between billed charges and the DSH-adjusted payment amount; The hospital's disproportionate patient percentage changed, affecting whether the hospital meets the DSH qualification threshold or the size of the DSH adjustment; The hospital's reported Medicaid fraction or SSI fraction used in the DSH calculation was inaccurate, resulting in an incorrect DSH payment adjustment. The group code paired with CARC 76 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-76 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.
Do Not Appeal This Code

Disproportionate Share Adjustment grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

How to Prevent PR-76

Also Filed As

The same CARC 76 may appear with different Group Codes:

CO-76 OA-76

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

Sources

  1. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/disproportionate-share-hospital
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/76
  4. Codes maintained by X12. Visit x12.org for official definitions.