PR 55: Experimental or Investigational
Treated as experimental or investigational.
Appeal with literature and the payer policy. Low win rate; triage by dollar value.
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- No BAA
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What PR 55 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. 55 also arrives as CO 55. 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 55, read that page instead.
Is It Worth Appealing?
Winnable with a clinician. Recoverable on the merits, but somebody clinical has to attest.
How to Appeal PR 55, Step by Step
Appeal with literature and the payer policy. Low win rate; triage by dollar value.
- 1Step 1: Read the remark code. Find the remark code printed next to PR 55 on the 835 or EOB. It says what the payer wants back.
- 2Step 2: Take the first action. Appeal with literature and the payer policy. Low win rate; triage by dollar value.
- 3Step 3: 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.
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 55 description
Treated as experimental or investigational.
Treated as experimental or investigational. 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 55 mean?
Treated as experimental or investigational. Patient responsibility. This one goes on the patient statement.
Can you appeal PR 55?
Winnable with a clinician. Appeal with literature and the payer policy. Low win rate; triage by dollar value.
How do I appeal a PR 55 denial?
Step 1: Read the remark code. Find the remark code printed next to PR 55 on the 835 or EOB. It says what the payer wants back. Step 2: Take the first action. Appeal with literature and the payer policy. Low win rate; triage by dollar value. Step 3: 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.
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How Much of This Is Sitting in Your Write-Off Pile?
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