PR-95: Plan Procedures Not Followed
The patient is responsible for this adjustment amount. Verify the balance and collect from the patient.
What Does PR-95 Mean?
With PR (Patient Responsibility), the amount adjusted under CARC 95 is owed by the patient. The payer determined that this portion — related to plan procedures not followed — falls under the patient's financial obligation per their plan benefits.
CARC 95 relates to plan procedures not followed. The payer requires specific authorization, certification, or referral for this service, and the claim was adjusted because that requirement was not satisfied.
Common scenarios that trigger this adjustment include: the provider did not obtain required prior authorization or precertification before rendering the service, and the payer denied the claim for failure to follow plan procedures; The patient's plan requires a referral from the PCP for specialist visits, and the referral was not obtained or not on file at the time of service; The provider is out of network and the plan requires preapproval for out-of-network services, which was not obtained. The group code paired with CARC 95 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 did not obtain required referral The patient sought specialist care without obtaining the required referral from their primary care physician, making the patient responsible for the charges | Most Common |
| Patient used out-of-network provider without plan approval The patient chose an out-of-network provider without obtaining the required preapproval from their plan, and the charges are assigned to the patient | Common |
| Patient did not follow plan's gatekeeper requirements The patient's HMO or managed care plan requires specific procedural steps that the patient did not follow before receiving services | Common |
How to Resolve
- Verify the adjusted amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the adjustment amount 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 adjustment amount, 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.
The patient did not follow the required plan procedures (referral, authorization, etc.). This adjustment correctly assigns financial responsibility to the patient. Collect from the patient.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-95:
| RARC | Description |
|---|---|
| N381 | Plan procedures require a referral or preauthorization that was not obtained Contact the patient's PCP to obtain a retroactive referral if possible → |
How to Prevent PR-95
- Educate patients about their plan's referral and authorization requirements during scheduling
- Remind patients to obtain referrals from their PCP before specialist appointments
- Provide patients with written information about their plan's network and authorization requirements
- Have patients sign an acknowledgment of financial responsibility if plan procedures are not followed
Also Filed As
The same CARC 95 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.cms.gov/medicare/health-plans/managed-care-marketing/guidelines
- https://www.aapc.com/resources/claim-adjustment-reason-code-carc
- https://www.mdclarity.com/denial-code/95
- Codes maintained by X12. Visit x12.org for official definitions.