CARC B7 Active

PR-B7: Provider Not Certified/Eligible for This Service on This Date

TL;DR

PR-B7 shifts the cost to the patient because the provider is not credentialed. Verify enrollment status and appeal to remove patient liability if the provider was actually authorized.

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-B7 Mean?

When paired with Group Code PR, the patient bears responsibility because the provider was not credentialed with their plan. This may occur when the patient sees a provider who is not in their network. Verify the credentialing status and appeal to remove patient liability if the provider was actually enrolled.

CARC B7 indicates the payer has no record of the provider being certified, credentialed, or enrolled to provide the billed service on the date it was rendered. This is a provider eligibility issue — the payer's system does not recognize the provider as authorized to bill for the service on that specific date.

Common causes include the provider's enrollment not being effective yet on the date of service, a lapsed certification or license, the provider not being credentialed for the specific service type, a Medicare enrollment gap, or a retroactive enrollment application that has not been processed. In some cases, the provider's credentials are current but the payer's records contain outdated or incorrect information.

Resolution typically involves verifying the provider's actual enrollment status, gathering proof of credentialing, and either resubmitting with the correct provider information or appealing with enrollment documentation.

Common Causes

Cause Frequency
Patient saw non-credentialed provider The patient received services from a provider who was not certified with their insurance plan, resulting in patient responsibility Common
Provider out of network The provider's credentials are not recognized by the patient's plan, shifting financial responsibility to the patient Common

How to Resolve

  1. Verify credentialing status Confirm whether the provider was enrolled with the patient's plan.
  2. Appeal if enrolled If the provider was credentialed, appeal with documentation to remove patient liability.
  3. Inform patient if not enrolled If the provider was not credentialed, inform the patient of their financial responsibility.
Appeal Guide

Appeal with provider enrollment documentation showing the provider was credentialed on the date of service to remove patient liability.

How to Prevent PR-B7

Also Filed As

The same CARC B7 may appear with different Group Codes:

CO-B7 OA-B7

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/b7
  3. https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers
  4. Codes maintained by X12. Visit x12.org for official definitions.