CARC 91 Active

PR-91: Dispensing Fee 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-91 Mean?

With PR (Patient Responsibility), the CARC 91 adjustment for dispensing fee 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 91 means the payer adjusted the payment based on dispensing fee 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: the pharmacy billed a dispensing fee higher than the contracted or allowable rate per the payer agreement, and the payer adjusted down to the contracted amount; The payer does not recognize a separate dispensing fee for the type of medication or administration method billed, such as certain pre-packaged or unit-dose medications; The payer's reimbursement methodology already includes the dispensing fee in the overall drug payment rate, and billing a separate dispensing fee results in a duplicate charge adjustment. The group code paired with CARC 91 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-91 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

Dispensing Fee 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-91

Also Filed As

The same CARC 91 may appear with different Group Codes:

CO-91 OA-91

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/part-b-drugs
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/91
  4. Codes maintained by X12. Visit x12.org for official definitions.