PR - Patient Responsibility

An ANSI Group Code is always shown with each ANSI reason code to indicate when you may or may not, bill a beneficiary for the non-paid balance of the services or equipment you furnished. Group codes are not used with Medicare Reference (REF) or Medicare Outpatient Adjudication (MOA) remark code entries.

PR - Patient Responsibility

A PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patient’s failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (reason code B4), excess charges on an assigned claim (reason code 42), excess charges attributable to rebundled services (reason code B15), charges denied as result of the failure to submit necessary information by a provider who accepts assignment, or services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

b. CO - Contractual Obligations

A CO group code identifies amounts for which the provider is financially liable. These include, participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, Gramm-Rudman reductions, or medical necessity denials/reductions. The patient may not be billed for these amounts.

c. OA - Other Adjustment

An OA group code is used when neither PR nor CO applies. At least one PR, CO or OA group code appears on each remittance advice. For example, OA would be used when a claim is paid in full at initial adjudication with reason code 93 and a zero amount, or with reason codes such as 69-85 that are components of payments rather than adjustments to payments. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.

d. CR - Correction to or Reversal of a Prior Decision

A CR group code is used whenever there is a change to a previously adjudicated claim. CR explains the reason for the correction; PR, CO and/or OA must always be used in tandem with CR to show the revised information. Separate reason code entries must be used in the NSF for the CR group entry, and any other groups that apply to the readjudicated claim.