PR 167: Diagnosis Not Covered
The diagnosis billed is not covered for this service.
Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits.
See a finished review first
- No patient data
- No BAA
- No charge
- No pitch
What PR 167 means
PR: Patient responsibility. This one goes on the patient statement.
So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
The same code, a different prefix. 167 also arrives as CO 167. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says CO 167, read that page instead.
Is It Worth Appealing?
Winnable with a clinician. Recoverable on the merits, but somebody clinical has to attest.
Why It Fires
In the order we see it.
The diagnosis billed is not on the payer's covered list for this service.
How to Appeal PR 167, Step by Step
Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits.
- 1Step 1: Read the remark code. Find the remark code printed next to PR 167 on the 835 or EOB. It says what the payer wants back.
- 2Step 2: Find the cause. Match the denial to one of the cause in Why It Fires above, and fix that one.
- 3Step 3: Take the first action. Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits.
- 4Step 4: Attach the documentation. A covered diagnosis that is already documented in the note, if one exists. Otherwise, an appeal on the merits citing the policy.
- 5Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window. See what an appeal letter must contain and the filing limits by payer.
The common mistake. Do not change the diagnosis to one that pays. Code what the record supports, and appeal if the record supports coverage.
Free: the Denial Code Appeal Playbook. 53 codes on one sheet: appeal, fix and resubmit, or let it go, and what to attach. Get the playbook
PR 167 description
The diagnosis billed is not covered for this service.
The diagnosis billed is not covered for this service. So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Your Questions Answered
What does PR 167 mean?
The diagnosis billed is not covered for this service. Patient responsibility. This one goes on the patient statement.
Can you appeal PR 167?
Winnable with a clinician. Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits.
Why does PR 167 happen?
The diagnosis billed is not on the payer's covered list for this service.
What documentation wins a PR 167 appeal?
A covered diagnosis that is already documented in the note, if one exists. Otherwise, an appeal on the merits citing the policy.
How do I appeal a PR 167 denial?
Step 1: Read the remark code. Find the remark code printed next to PR 167 on the 835 or EOB. It says what the payer wants back. Step 2: Find the cause. Match the denial to one cause: The diagnosis billed is not on the payer's covered list for this service. Step 3: Take the first action. Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits. Step 4: Attach the documentation. A covered diagnosis that is already documented in the note, if one exists. Otherwise, an appeal on the merits citing the policy. Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window.
Most searched: CO 97 · CO 96 · OA 23 · PR 204 · CO 109 · CO 197 · CO 45 · CO 50
How Much of This Is Sitting in Your Write-Off Pile?
No patient data. No BAA. No charge.
Upload your denial summary for the last 90 days. 4 columns: payer, CARC code, count, billed amount. You get back which were winnable and what they were worth.