Not covered under the patient’s current benefit plan.
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.
Usually lost. Recoverable only with unusual evidence. Triage by dollar value.
In the order we see it.
The service is excluded from the patient's current benefit plan.
Check for an ABN or a patient waiver, then bill the patient or write off.
The documentation, not the argument.
An ABN signed before the service was delivered.
The common mistake. Do not bill the patient on a Medicare claim without a valid ABN signed in advance.
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.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound