PR-95: Plan Procedures Not Followed
The patient is responsible for not following their plan's procedures, such as getting a referral. Bill the patient for the service and assist them in understanding their plan requirements.
What Does PR-95 Mean?
PR-95 shifts the financial responsibility to the patient. The payer determined that the patient did not follow a required plan procedure — such as failing to obtain a referral from their primary care physician before seeing a specialist, or using an out-of-network provider without required pre-approval. The provider can bill the patient for the full amount of the denied service.
When CARC 95 appears on a remittance, the payer is telling you that someone — either the provider or the patient — did not follow a required procedural step outlined in the insurance plan before the service was delivered. This is one of the most preventable denial codes in medical billing because it almost always traces back to a verification gap in the pre-service workflow.
The most frequent trigger is a missing prior authorization. The payer required pre-approval for the service, and the authorization was not obtained before care was rendered. Missing referrals are the second most common cause, particularly for plans that require a primary care physician referral before the patient can see a specialist. Non-compliance with step therapy protocols, where the payer requires the patient to try lower-cost treatments before more expensive ones, is another trigger.
The group code paired with CARC 95 determines the financial impact. CO-95 places the responsibility on the provider — you rendered the service without following the required plan procedure, and your contract holds you liable. PR-95 places it on the patient — they sought care without obtaining their plan's required referral or following other member-side procedures. In both cases, the accompanying RARC code will specify exactly which plan procedure was not followed, so always read the remark code before deciding on your resolution strategy.
Common Causes
| Cause | Frequency |
|---|---|
| Patient did not obtain required referral The patient's plan requires a referral from their primary care physician before seeing a specialist, and the patient sought specialty care without obtaining the referral first | Most Common |
| Patient used out-of-network provider without plan approval The patient's plan requires prior approval for out-of-network services, and the patient received care from a non-participating provider without following the required approval process | Common |
| Patient did not follow step therapy requirements The patient's plan requires trying lower-cost or first-line treatments before more expensive options, and the patient or provider skipped required steps in the therapy sequence | Occasional |
How to Resolve
Identify the specific plan procedure that was missed, attempt to satisfy it retroactively, and either resubmit or appeal with supporting documentation.
- Verify the patient's plan requirement Confirm which specific plan procedure the patient did not follow by reviewing the RARC and the patient's benefit details.
- Help the patient resolve retroactively Contact the patient and explain the denial. Assist them in obtaining the required referral or authorization retroactively if their plan permits it.
- Resubmit if the requirement is satisfied If the patient obtains the referral or authorization retroactively, resubmit the claim with the documentation attached.
- Bill the patient if unresolvable If the plan procedure cannot be satisfied retroactively, transfer the balance to the patient's account and send a statement explaining the charges and the reason for the denial.
This adjustment is correct per the patient's benefit plan. The amount is the patient's financial responsibility. Collect from the patient rather than appealing.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-95:
| RARC | Description |
|---|---|
| N657 | This should be billed with the appropriate prior authorization or referral number. Obtain and resubmit. |
| N386 | This decision was based on a plan of care or pre-authorization/pre-certification requirement. |
| MA130 | Your claim contains incomplete or invalid information, and no appeal rights are afforded because the claim was unprocessable. |
How to Prevent PR-95
- Educate patients about their plan's referral and authorization requirements during registration and before scheduling specialty visits
- Verify that the patient has an active referral on file before the appointment and contact the PCP office if one is needed
- Provide written information to patients about their plan's procedures for accessing specialty or out-of-network care
- Implement automated referral tracking that flags patients without an active referral before their scheduled appointment
General Prevention
- Verify the patient has an active referral on file before the appointment and contact the PCP office if one is needed
- Implement automated referral tracking in the practice management system to flag patients without active referrals
Also Filed As
The same CARC 95 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/95
- https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
- https://carecloud.com/continuum/denial-codes-in-medical-billing/
- Codes maintained by X12. Visit x12.org for official definitions.