PR 27 Denial Code | Everything You Need to Know

Are you tired of dealing with the PR 27 code on your denied billing claims? This comprehensive guide dives into the common reasons for its frustrating denials. We also outline effective strategies that you can implement to prevent them.

Also, discover how we reduce your claim denial rate with the professional denial management services at Health Quest Billing.

PR 27 Denial Code Descriptions

PR 27 is a code mentioned on specific reimbursement claims that are denied by insurance companies. The full form of PR is Patient Responsibility. This category comprises those components of a medical bill that have to be paid by patients.

This code means that the relevant insurer will not cover the cost of the healthcare services provided. As a result, the relevant patients have to pay for those services from their own pockets. This happens when those expenses are added to bills after the insurance coverage of those services ends.

Common Reasons for the PR 27 Denial Code

There are a lot of reasons that lead to claims getting denied with the PR 27 code. Let’s take a look at them in detail:

• Outdated Patient Insurance Information

The insurance information in a patient’s file may have expired or changed. Any claims submitted using that old information will be denied. Insurance companies verify coverage before processing claims. An outdated policy number will not match their records.

A patient may also change their insurance provider without informing their healthcare provider. The provider may end up billing the old insurance company. This is a classic example that results in a PR 27 denial because the old plan is inactive.

• Delays in Claim Submission

Claims must be submitted within a certain timeframe to be eligible for reimbursement. There are often delays in submitting the claim from the hospital’s end. It is possible that the insurance coverage of that patient ends before the claim is received. Such cases usually end with claim denials.

A healthcare provider may take several months to submit reimbursement claims. During this time, the insurance coverages of their patients may expire or change. This also results in a PR 27 denial as its claims are outside the coverage period.

• Lack of Coverage Verification

Verifying a patient’s insurance coverage before providing services is crucial. If this step is skipped, services may be provided to patients who do not have active coverage. As a result, you may end up with claim denials. A healthcare provider may fail to verify insurance coverage on the day of the appointment. Since their coverage had ended, the subsequent claim will be denied with a PR 27 code.

• Changes in Insurance Plans

Patients may switch insurance plans without informing their healthcare providers. If the provider submits a claim to an old and inactive insurance plan, the claim will be denied. A patient may change their job and get a new insurance plan.

In many cases, they forget to inform their healthcare provider. The provider bills the old and inactive plan, so their claim gets denied.

• Billing Errors

Errors in the billing process can lead to delays in claim processing. They can be incorrect dates of service, wrong patient information, and coding errors. These delays can push the claim submission past the coverage period.

A billing department can enter the wrong date of service. It can cause a delay in processing the claim. By the time the error is corrected and the claim is resubmitted, the patient’s coverage has ended. And the healthcare provider will receive a PR 27 denial.

• Incorrect or Missing Documentation

Insurance companies require specific documentation to process claims. The claim can be denied if the required documents are either missing or incorrect. A provider may submit a claim without the necessary medical records. It is also possible that their information might just be incomplete. The insurance company will deny the claim as it cannot verify the services provided.

• Eligibility Issues

Patients might also be ineligible for certain services under their insurance plan. The claim will be denied if the provided services are not covered by the patient’s plan. A patient may receive an uncovered medical procedure under their insurance policy. The provider will submit a claim which will get denied due to the lack of eligibility for that service.

• Coordination of Benefits (COB) Issues

A patient can have multiple insurance policies so their COB must be handled correctly. Their claim can be denied if it is not submitted to the correct primary insurance. A patient with two insurance plans may not inform the provider about their secondary one. The provider may submit the claim to the wrong insurance plan first and end up with a denial.

• Pre-Authorization Requirements

Some services require pre-authorization from insurers before they are performed. Reimbursement claims can also be denied if those pre-authorizations are not obtained. Consider a provider who performs a surgery without obtaining them from insurers. The relevant claim will be denied as obtaining pre-authorizations is mandatory.

• Patient Responsibility

Certain costs are the responsibility of your patients. They include copayments, deductibles, and services that are not covered by insurance. A healthcare provider will get their claims denied if they bill the insurance for these costs. In such cases, the insurance company is billed for a service that is supposed to be paid out-of-pocket. The claim will be denied because it falls under the patient’s responsibility.

Strategies to Resolve PR 27 Denial Code

You can implement several strategies to prevent the above reasons for the PR 27 code. We have explained them below just for you:

 

• Regularly Update Patient Insurance Information

Establish a process to update patient insurance information at each visit. You should ask patients to confirm their insurance details during appointment scheduling. Verifying that information at check-in is another ideal option.

Use electronic verification tools to cross-check those details in real time. This will ensure that the most current insurance information is on file. It will reduce the risk of claims being denied due to outdated information.

• Timely Claim Submission

Implement an optimized billing process to ensure claims are submitted promptly. You can do that by setting internal deadlines for claim submissions. Those deadlines should be well within the insurance company’s filing limits. Automate claims submissions through electronic health record (EHR) systems.

Regularly audit the billing process to identify and address delays. These practices reduce the risk of claims being denied due to late submission. They also ensure that those claims are processed within the coverage period.

• Thorough Coverage Verification

Conduct comprehensive insurance coverage verification before providing services. Use electronic eligibility verification systems to check coverage in real time. Train your staff as well to verify coverage details. They can be policy numbers, coverage dates, and pre-authorization requirements.

Establish protocols for re-verifying insurance information for recurring patients. It ensures that your services are provided only to the patients with active coverage. This way, you can minimize the risk of claim denials.

• Proactive Communication with Patients

Educate and remind your patients to inform you about any changes in their insurance plans. You can send them reminders through appointment confirmations and follow-up communications. Provide them with a checklist of details to update like insurance details.

This practice keeps you informed of any changes in insurance plans. You can also prevent your claims from being denied due to inactive plans.

• Accurate Billing Practices

Healthcare providers must ensure accuracy in their billing process. They can do that by implementing thorough training programs. These programs can be for their billing staff to excel at coding and documentation practices.

Utilize billing software that includes checks for their common errors. Conduct regular audits to identify and correct them. By doing this, you can reduce the likelihood of errors that lead to claim delays and denials.

• Ensure Proper Documentation

It is important to maintain complete and accurate documentation for all reimbursement claims. Develop standardized documentation procedures to ensure all required information is included. Use electronic health records to improve your documentation process.

This will ensure that all necessary information is available for claim processing. It will reduce the risk of denials as well due to either missing or incorrect documentation.

• Verify Eligibility for Services

You should confirm that your patients are eligible for the services provided under their insurance plan. Check their insurance benefits and limitations before providing those services. Consult with their insurance company as well and check if it has doubts about coverage.

This way, you can prevent claim denials due to ineligible services. You can ensure that the provided services are covered under the patient’s plan.

• Proper Coordination of Benefits (COB)

If patients have multiple insurance policies, they should know how to handle them. You can identify all of their policies to establish the primary and secondary ones. Submit claims to the primary insurer first and follow it with the secondary insurer.

Keep detailed records of the Coordination of Benefits information for each patient. Ensure claims are processed by the correct insurer. This will help reduce the risk of denials due to COB issues.

• Obtain Pre-Authorizations

For this, you have to first secure pre-authorizations for services that require them. Next, maintain a list of services that require pre-authorization. This way, you can check them through your understanding and pre-service verification.

Train your billing staff on this pre-authorization process. Follow up with insurers to confirm that the pre-authorizations are in place before providing services. As a result, you can ensure compliance with pre-authorization requirements and prevent denials.

• Address Patient Responsibility

Clearly communicate patient financial responsibilities and separate billing for out-of-pocket expenses. You should provide detailed billing information to patients before implementing your services. It should include accurate estimates of copayments and deductibles.

Set up clear policies for collecting patient payments at the time of service. Use patient portals to allow easy access to billing information and payments. This will avoid billing insurance for costs that are the patient’s responsibility. This is how we prevent claim denials due to billing errors.

How Does Health Quest Billing Help Prevent Claim Denials?

Health Quest Billing excels in preventing claim denials for hospitals. We have advanced software and skilled professionals to ensure accuracy in claim submissions. Our approach begins with a thorough verification of patient insurance details.

This enables us to preempt issues before they become a problem. They include pre-existing condition waiting periods and effective date discrepancies. We also focus on proactive measures like obtaining pre-authorizations.

Our experts can educate your patients on insurance limitations upfront as well. This practice ensures that your treatments are covered whenever you conduct them. This minimizes surprises and denials like PR 27.

Our commitment to comprehensive data collection protects you against information errors. Regular audits and continuous staff training are integral to our strategy. They enable us to swiftly identify and rectify administrative errors.

We also maintain clear documentation and strictly follow insurer guidelines. This is how we are able to prevent claim denials effectively. As a result, we can support our hospital partners in achieving operational efficiency.

The Bottom Line

Understanding and addressing the reasons behind PR 27 denials is crucial. You can prevent them by regularly updating patient information and promptly submitting claims. It is also better to carefully verify patient coverage and maintain accurate billing practices.

These proactive measures can ensure that your services are covered. Contact Health Quest Billing and prevent all financial losses caused by PR 27 denials.