Insurance companies reject a claim using the PR 227 denial code to indicate that the patient’s primary insurance will not pay for the claim. Simply saying, it’s the patients who’re responsible for paying the costs of the treatment or medical procedure.
Another important aspect, towards which the PR 227 code points, is the missing or incomplete information in the claim. PR 227 denial code also reminds healthcare providers to include all vital information and details in the claim prior to submitting to the payor.
Claim denials have always been a headache for healthcare providers. In the medical billing world, there are numerous
that indicate the specific reason for denying a medical bill. One such code that we’re going to discuss today is denial code PR 227. If you’re a healthcare provider and face a denial with PR 227, you need to understand the dynamics of this code to figure out the intricacies.
Codes with a prefix PR stand for ‘Patient Responsibility’ and when applied in the claim, mean that the patient is responsible for paying the expenses, i.e., co-pays, deductibles, and coinsurance amounts. You may also face a denial code specified with PR 227, in case the patient doesn’t have coverage on the date of service.
PR 227 Denial Code Description
Denial code PR 227 is a common code in the medical billing world and signifies that the patient’s primary insurance will not pay for the claim. One reason for this denial could be submitting the claim to the wrong insurer. Second is that the primary insurance of the patient isn’t valid or active when the patient requires medical care.
Another scenario in which denial code PR 227 is triggered is when the claim is submitted by mistake to another insurance company thinking they are the primary payor; when they aren’t the primary insurer. It can happen owing to a documentation error, missing details or inclusion of inaccurate information like claim coding or incorrect insurance information.
PR 227 is a claim adjustment reason code (CARC) where the group code PR stands for ‘patient responsibility’ to show that it’s the patient’s responsibility/liability to pay for the treatment.
Why do you see the PR 227 denial code?
Here’s why you see denial code PR 227 in claim forms.
- The patient information in the claim is either incomplete or missing.
- Information like treatment provided and methodologies is missing or unclear.
- The patient hasn’t responded to the information requests.
- Documentation provided is either insufficient or doesn’t fulfill the payor criteria.
Common Reasons Behind Denial Code PR 227
When it comes to causes of PR 227 denial, there could be many. We’ve explained the most common reasons behind this denial.
Wrong Primary Insurance Information
Inaccurate information about the primary insurance company is the most frequent reason behind this denial. For instance, when a claim is submitted to another payor, i.e., secondary insurer instead of primary insurer, the receiving insurance company will deny it straightaway using PR 227 denial code.
Invalid or Inactive Insurance
If the insurance provider figures out that the patient’s primary insurance is either invalid or inactive, they’ll slap a PR 227 denial on the claim. It can happen when the patient changes their policy plan, misses a payment, or when the insurance coverage has expired.
Coordination of Benefits Issue
There are times when correct coordination between more than one payors must be established. If an insurer is unaware of other payers involved, it will process the claim only after verifying that the primary payer is responsible for covering the costs first.
Wrong Insurance Plan Type
Another reason for providers to face PR 227 denial is when they misidentify the insurance plan, like Medicaid or a group health plan. If they submit a claim to a commercial payor like Aetna, Cigna, BCBS instead of Medicare, which is the primary payor, they’ll have to deal with a denial.
Duplicate Billing
Resembling the reason above, another cause of seeing PR 227 code could be sending the claim to the wrong insurer multiple times. This scenario creates confusion regarding the party that is responsible for payment. Hence, you get a PR 227 denial.
Missing or Incomplete Information
If you don’t include all the essential information in the claim, like primary insurance details, subscriber numbers, and policy numbers, the insurance company has the right to deny the claim. They can also deny the claim using PR 227 if the healthcare provider doesn’t identify/highlight the primary insurance.
Denial Code PR 227 VS. other Denial Codes
When dealing with claim denials, it’s essential to understand how denial code PR 227 differs from other widely used denial codes in medical billing. We’ve mentioned their description, common causes, the responsible entity, and how to resolve them.
This comparison table helps healthcare providers and their staff in effective denial management and also provides basic knowledge to tackle other denials, too.
Comparison of PR 227 with Other Common Denial Codes
| Denial Code | Description | Common Causes | Responsible Entity | How to Resolve? |
| PR 227 | Information requested from the patient not provided or incomplete | Patient did not submit required forms or details | Patient | Contact the patient, explain the missing information, and resubmit |
| CO 97 | Service not covered under the patient’s policy | Non-covered service, benefit exclusion | Provider/Patient | Verify coverage before service, educate patient, avoid non-covered services unless agreed |
| CO 16 | Claim lacks required information | Missing modifiers, invalid codes, incomplete fields | Provider | Correct and complete claim form, ensure coding accuracy |
| CO 29 | The time limit for claim submission has expired | Late filing | Provider | Track claim deadlines, submit within payer timelines |
| PR 1 | Deductible amount | Patient has not met deductible | Patient | Inform patient, collect deductible amount |
| OA 18 | Duplicate claim/service | Claim submitted more than once for same service/date | Provider | Review claim history, submit only once per service/date |
How to Prevent PR 227 Denial Code?
Prevention is better than cure. Stands true for denial code PR 227. Want to prevent PR 227 from affecting your cash flow? Here are some efficient and time-tested, industry’s best preventive practices to keep your claims tip top, decrease the denial rate, and enhance your reimbursements.
Enhance Patient Communication
Streamline communication with the patients and never miss a detail that may result in a denial. Also, educate your clinic staff on strengthening provider-patient ties via smooth and professional communication. This way, you gather all the required information from the patients. It includes COB and other necessary information to reduce the risk of 227 denials.
Integrate Technology
Another way to reduce the risk of PR 227 is by implementing online portals and electronic forms. It allows you to streamline your data collection efforts and helps you ensure that the patient data and insurance eligibility are up-to-date. Integrating technology and automation not only reduces the burden on your shoulders but lowers the chances of PR 227 denials due to missing or outdated patient details.
Improve Claims Submission Process
Ensuring accuracy in claim creation processes like appending the precise coding, filling the accurate information and specifying the primary insurer is one way of mitigating PR 227. Once you or your staff are done with the claim creation process, it is suggested to go through it all over again. Claim scrubbing or claim cleanup tools can simplify your job by identifying any coding errors or inaccurate information.
Stay Up-To-Date with Insurance Guidelines
Most commercial payors have their own set of guidelines. The best part is that these guidelines or policies change with the passage of time. Ensuring continuous communication with payors and staying current with their guidelines helps to submit claims based on their requirements. This way, you can stay safe from the unwanted denial caused by PR 227.
Establishing clear communication with payors enables healthcare providers to stay up-to-date with any developments, like a payor sending a letter to the patient to ask for missing information. Or if they’ve received a response from them within 30 days of issuing a letter.
Track Claim Status
This preventive measure requires you to be proactive. Another best way to reduce claim denials is by continuous monitoring and tracking of claims. Conduct regular follow-ups with the payor to see if there’s any requirement you’ve missed. In case they demand something else, you can quickly act on it and hence minimize the chances of PR 227 denials.
How to Resolve PR 227 Denials?
Preventing denials in the first place must be your first priority; however, if you face denials caused by PR 227 code, you can control the damage with I-Med Claims’ industry-leading management and resolution techniques aimed specifically for denial code PR 227. Here are some of the actionable tips used by our experienced denial management experts.
Verify The Denial Reason
If you’re unsure of the cause, call the insurance company and verify the reasons for denial. They’ll guide you about the reason behind the denial, for instance, missing prior authorization with private insurance like Delta or United Healthcare.
Rectify The Issue
Once you know the issue, the second stage is to rectify the error by refilling the claim. For instance, if the modifier was missing, you add it and resubmit it. The addition of the required modifier helps the payor understand the treatment variations, special circumstances, and additional details.
Appeal with Correct Documentation
There are occasions where even after confirming authorization and refilling the claim with correct details, the denial persists. If such a situation arises, provide the necessary documentation that is carefully compiled with every detail included. These could be treatment notes and documentation emphasizing medical necessity.
Update Internal Processes
Streamline your billing cycle and update internal processes especially the communication between departments like billing, scheduling and claim creation departments. Investigate denial patterns and implement changes based on these patterns to prevent future denials. One upgrade could be setting an EHR reminder for preauthorization of a particular treatment.
How Denial Code PR 227 Affects Your Practice’s Revenue?
Like all denials, PR 227 also has an adverse effect on your practice’s revenue and income stream. If you don’t heed the prevention and resolution tips, the financial impact can worsen over time. Apart from denied and delayed payments, PR 227 denials can also hurt your credibility in the long term.
Here’s how denied claims due to PR 227 code can impact your financial and operational activities.
- You can experience delayed payment due to the gathering of the correct information to be included afterwards
- Denial management not only costs you financially, but also results in more effort in resolving and resubmitting claims
- Patient follow-up and chasing claims with the payor can waste a lot of your valuable time
- Denial management and other background processes are resource-heavy and require additional staff
- Going back and forth with payors and patients can compromise on the quality of patient care
- Claim denials increase administrative tasks as you have to refill claims and resubmit them on time
Financial Impact of Denial Code PR 227
Here’s a sample size of the financial impact of PR 227 denial code on healthcare providers. It is important to note that the rates and time taken to resolve a denial differs based on the payor, location, reason and complexity of denial. We’ve included the averages here for easy understanding of healthcare providers.
| Potential Lost Revenue | Average Time to Resolve | Staff Hours Involved | Frequency by Payer Type |
| $400-$1,400 per claim | 2-4 weeks | 2-4 hours | Varies widely by payer |
Overturning PR 227 Claim Denials
Effective management and resolution of PR 227 denials or any other denial is essential for ensuring timely and complete reimbursements. Not only does it help maintain the financial stability of your healthcare practice, but it also lowers the administrative burden.
Tackling delayed processing, collecting the required information from patients, refilling, and resubmitting claims can take a lot out of you. As a healthcare provider, you must be proactive against denials as they can strip you of deserved cash.
Partner with a renowned and experienced medical billing company like I-Med Claims that helps you in early identification of errors. We enable you to prevent denials by customizing and streamlining your revenue cycle through advanced strategies and a highly professional workforce.
We deeply analyze the denial patterns and help you identify common errors, such as information collection. This way, uprooting a problem is easy and you experience smooth claim processing and a high approval rate, resulting in enhanced payment collection and minimized revenue leaks.
With I-Med Claims by your side, you don’t have to worry about denied or delayed revenue, engaging in long and technical communication with payors regarding denials and their resolution. Leave it to us while you focus on providing compassionate care to patients.
Final Say
As a healthcare provider, if you face PR 227 denial code, there’s a deep rooted problem with your information collection process and the details of your patient’s primary insurance. If there’s no clear information regarding who’s going to reimburse for the medical services you’ve provided, chances are that you’re going to face a denial.
Partner with a top medical billing agency in your state that reaches the root cause of the problem and helps you rectify the errors. At I-Med Claims, we know how to dive deep and understand the complexity of the situation. We start by thoroughly checking the patient’s insurance coverage, and follow proper procedures to ensure that you don’t have to face denials and run behind the revenue.
Even if there are denials, we resolve them expertly so that your medical practice remains afloat and your attention never diverts from providing world-class treatment services to patients.
