CARC P6 Active

PR-P6: Adjustment Based on Entitlement to Benefits — P&C Only

TL;DR

The patient's entitlement to P&C benefits was denied or adjusted. Verify the patient's P&C policy coverage and appeal with policy documentation if the entitlement determination is incorrect. Otherwise, redirect to health insurance.

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-P6 Mean?

CARC P6 applies to property and casualty claims and indicates the payer adjusted or denied the claim based on the patient's entitlement to benefits under the P&C policy. The payer determined the patient is not entitled to P&C benefits for this claim due to policy exclusions, expired coverage, reached benefit limits, or other entitlement restrictions.

This code addresses the fundamental question of whether the patient qualifies for benefits under the P&C policy — separate from whether the treatment itself is covered. If the patient's entitlement has expired, the policy excludes the circumstance, or coverage limits have been reached, the claim cannot be processed under P&C.

How to Resolve

Verify the patient's P&C entitlement, appeal with policy documentation if incorrect, or redirect to health insurance.

  1. Verify P&C policy entitlement Review the patient's P&C policy for coverage terms, exclusions, and benefit limits.
  2. Check entitlement period Confirm whether the patient's entitlement period has expired or benefits have been exhausted.
  3. Appeal with policy documentation If the entitlement determination is incorrect, appeal with the P&C policy showing active coverage and entitlement.
  4. Redirect to health insurance If P&C entitlement has ended, redirect the claim to the patient's health insurance.
Do Not Appeal This Code

Adjustment Based on Entitlement to Benefits — P&C Only 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.

Also Filed As

The same CARC P6 may appear with different Group Codes:

CO-P6 OA-P6

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://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.cms.gov/medicare/coordination-benefits
  3. Codes maintained by X12. Visit x12.org for official definitions.