PR-78: Non-Covered Days / Room Charge Adjustment

What Does PR-78 Mean?

PR-78 assigns the non-covered day charges to the patient. This typically occurs when the patient has exhausted all available benefit days under their plan — for Medicare patients, this means 90 standard days plus 60 lifetime reserve days per benefit period are used. For commercial plans, the plan's maximum covered days have been reached. The provider should bill the patient for these charges.

When CARC 78 appears on a remittance, the payer is telling you that certain hospital days or room charges fall outside the scope of coverage. This is not a blanket claim denial — the payer may have paid for part of the stay and is adjusting specific dates that it considers non-covered.

The reasons behind CARC 78 vary significantly depending on the group code. Under CO, the non-covered days typically result from a payer's retrospective determination that the patient no longer met inpatient criteria on those dates, that the stay exceeded a contractual day limit, or that prior authorization lapsed before the patient was discharged. These are among the most frequently appealed inpatient adjustments because they often hinge on clinical judgment about medical necessity.

Under PR, the picture changes: the patient has exhausted their covered benefit days. For Medicare patients, this means all 90 standard days plus 60 lifetime reserve days per benefit period have been used. For commercial plans, it means the annual or per-admission day limit has been reached. PR-78 shifts the financial burden directly to the patient. The provider should verify the benefit day count, check for secondary coverage, and issue an Advance Beneficiary Notice if the exhaustion was foreseeable.

OA-78 appears less frequently, primarily in coordination of benefits scenarios. Tracking CARC 78 patterns by payer and service line helps identify systemic issues with authorization management, utilization review timing, or discharge planning.

Common Causes

How to Resolve

Identify which days were denied and why, verify the denial basis against coverage terms, then write off, appeal with clinical documentation, or bill the patient.

1. Verify benefit day exhaustion Confirm with the payer that the patient has truly exhausted all covered days, including any lifetime reserve days. Benefit day counts can sometimes be miscalculated.
2. Check for secondary coverage Determine whether the patient has Medigap, supplemental insurance, or any secondary payer that could cover the non-covered days.
3. Transfer to patient ledger Move the non-covered day charges to the patient's responsibility account. Generate a clear statement showing which dates are the patient's responsibility and the per-day charge.
4. Contact the patient and arrange payment Reach out to explain the benefit day exhaustion, the amount owed, and available payment options. Offer a payment plan for large balances.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-78:

How to Prevent PR-78

• Verify remaining benefit days at admission and track them throughout the stay
• Notify patients and their families when benefit day limits are approaching
• Issue Advance Beneficiary Notices (ABNs) for Medicare patients before benefit days run out
• Check for secondary or supplemental coverage at registration to identify additional payers
• Flag patients with high utilization history in scheduling systems for proactive financial counseling

General Prevention

• Verify the patient's remaining benefit days at admission and notify the patient of potential out-of-pocket liability before coverage limits are reached
• Check for secondary insurance or supplemental coverage that could extend inpatient day coverage
• Inform patients in advance when their room type or accommodation level exceeds plan coverage
• Proactively issue Advance Beneficiary Notices (ABNs) for Medicare patients approaching their benefit day limits

Also Filed As

The same CARC 78 may appear with different Group Codes:

Related Denial Codes