PR-78: Non-Covered Days / Room Charge Adjustment
The patient owes this non-covered days / room charge adjustment. Verify the balance and collect from the patient.
What Does PR-78 Mean?
With PR (Patient Responsibility), the non-covered days / room charge adjustment is the patient's financial obligation. The insurer processed the claim, applied the patient's plan benefits, and this amount is owed directly by the patient. The most common scenario is the patient's benefit plan limits the number of covered inpatient days, and the patient is responsible for charges beyond the covered period.
CARC 78 indicates non-covered days / room charge adjustment. 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 determines that the patient's inpatient stay exceeded what is medically necessary based on clinical criteria, and the excess days are denied as non-covered; The provider did not obtain or renew prior authorization for continued inpatient days, resulting in the unauthorized days being denied; The patient was placed in a private room when only semi-private room charges are covered, and the difference is adjusted as non-covered. The group code paired with CARC 78 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 responsible for non-covered inpatient days The patient's benefit plan limits the number of covered inpatient days, and the patient is responsible for charges beyond the covered period | Most Common |
| Room upgrade elected by patient The patient requested a private room or upgraded accommodations that exceed the plan's covered room type, making the patient responsible for the difference | Common |
| Benefit period exhausted The patient has exhausted their inpatient benefit days for the benefit period, and remaining days are the patient's responsibility | Common |
How to Resolve
- Verify the non-covered days / room charge adjustment Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the non-covered days / room charge adjustment was applied correctly per plan terms.
- Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
- Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the non-covered days / room charge adjustment, and the balance the patient owes.
- Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
- Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
This adjustment correctly assigns financial responsibility to the patient per the benefit plan terms. Collect the balance from the patient rather than appealing.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-78:
| RARC | Description |
|---|---|
| N381 | Consult your benefit plan for information about covered inpatient days and patient financial responsibility Review the patient's benefit plan to confirm the non-covered day determination → |
How to Prevent PR-78
- Inform patients of their inpatient benefit day limits before or during admission
- Obtain signed financial responsibility agreements when patients elect room upgrades
- Monitor benefit period utilization and notify patients when they are approaching benefit limits
- Provide patients with cost estimates for non-covered days
Also Filed As
The same CARC 78 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps
- https://www.aapc.com/resources/claim-adjustment-reason-code-carc
- https://www.mdclarity.com/denial-code/78
- Codes maintained by X12. Visit x12.org for official definitions.