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.

How to Appeal a Health Insurance Denial

Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to appeal a coverage denial, there are several strategies that can bolster your case.

Some health-coverage problems — such as when your doctor enters a wrong code on a claim form — can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you.

First, figure out what led to the denial of coverage and learn your insurer’s procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can’t be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.

You will need the denial letter. You should also get a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Corp. and Aetna Inc., post their medical policies online.

Top 5 Reasons for Medicare Claim Denial

Medicare claim denial may take any Medicare beneficiary by surprise. Perhaps you, too, have been shocked to find that Medicare denied a claim that you were sure would be paid. Medicare offers broad, comprehensive medical and hospital coverage for eligible beneficiaries and can pay for most medically necessary services. A little known Medicare secret is that Medicare's coverage guidelines are far more flexible and far less restrictive than those of most private insurance companies. However, sometimes Medicare claims may deny for seemingly incomprehensible reasons. The chances are that if you have experienced a Medicare claim denial, you have fallen prey to one of the 5 basic reasons for Medicare claim denial. This article will tell you what they are, and what you can do to see that Medicare reverses its denial and pays on your claims.

Provider Error

The number one reason for claim denial in the Medicare system is probably due to error in either the way the claim is submitted or in the information provided. This often occurs when the provider omits information needed by Medicare to process the claim. In some cases, this may lead Medicare to think that the services are not medically necessary. In other cases, a provider may bill Medicare for the wrong service. When these situations arise, it is necessary to advise the provider to either get Medicare the information it needs to process the claim, or advise the provider to resubmit the claim for the service you received. A common example of provider error is when a beneficiary receives a covered pap and pelvic exam, but the doctor office bills these services as an office visit. In such a case, Medicare will deny the claim. This is easily corrected by the doctor office resubmitting the claim and billing Medicare for the exact services received.

Medical Necessity Denials