CARC B1 Active

PR-B1: Non-Covered Visits

TL;DR

PR-B1 means the patient owes for non-covered visits. Verify the denial is correct, then collect from the patient. Appeal if the visits should be covered.

Action
Collect from Patient
Who Pays
Patient
Appeal
Yes
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-B1 Mean?

When paired with Group Code PR, the patient is financially responsible for the non-covered visits. This is appropriate when visits exceed plan benefit limits, the service type is non-covered, or the patient chose an out-of-network provider. Collect from the patient after verifying the denial is correct.

CARC B1 indicates that the billed visits or services are not covered by the patient's insurance plan. This is a broad non-coverage denial that can stem from multiple causes: the visit type may be explicitly excluded from the plan, the patient may have exhausted their allowed number of visits for the benefit period, required prior authorization was not obtained, the provider is out of network, or the payer determined the visits were not medically necessary.

The resolution path depends on the specific reason for non-coverage. If the visits are genuinely excluded from the plan, there is limited recourse. If the denial resulted from missing authorization, coding errors, or incorrect benefit tracking, correcting the issue and resubmitting or appealing is appropriate. If medical necessity is contested, a clinical appeal with physician documentation is the appropriate path.

Common Causes

Cause Frequency
Visits exceed plan benefit limits The patient has used all covered visits and any additional visits are the patient's financial responsibility Most Common
Non-covered service type The type of visit (e.g., certain wellness visits, alternative medicine) is not covered under the patient's plan Most Common
Out-of-network visit The patient chose an out-of-network provider and the plan does not cover out-of-network visits Common

How to Resolve

  1. Verify the visits are non-covered Confirm the visits are indeed not covered under the patient's plan.
  2. Inform the patient Send a clear statement explaining the patient's responsibility and the reason.
  3. Appeal if incorrect If the denial is wrong, appeal on behalf of the patient with coverage documentation.
  4. Establish payment plan if needed Work with the patient on payment arrangements if necessary.
Appeal Guide

Appeal with documentation showing the visits should be covered. Include clinical records supporting medical necessity and any plan language that supports coverage.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-B1:

RARC Description
N130 Alert: You may need to review plan documents or guidelines. Review plan documents to confirm the patient's visit benefit limits →

How to Prevent PR-B1

Also Filed As

The same CARC B1 may appear with different Group Codes:

CO-B1 OA-B1

Related Denial Codes

PR-238 — Claim Spans Eligible/Ineligible Periods - Ineligible Reduction PR-B8 — Alternative Services Available — Should Have Been Utilized PR-149 — Lifetime Benefit Maximum Reached PR-197 — Precertification/Authorization/Notification Absent PR-201 — Patient Responsibility via Set-Aside Arrangement

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/b1
  3. https://www.cms.gov/regulations-and-guidance/guidance/manuals
  4. Codes maintained by X12. Visit x12.org for official definitions.