Sometimes medical claim denials don’t stem from coding errors or authorization slips on the provider’s side. Rather, they are caused by missing patient information or a lack of cooperation. These types of denials are often indicated via the PR 227 denial code.
In this guide, we will discuss what code 227 represents and how you can deal with it. So, let’s start.
PR 227 Denial Code – Description
To understand the PR 227 denial code, we must first look at its components: the Group Code (PR) and the Claim Adjustment Reason Code (CARC 227). Let’s simplify them one by one.
The CARC 227 is defined as:
“Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).”
This definition is self-explanatory. So, let’s now explain what “PR” signifies.
The PR is a group code. It stands for “Patient Responsibility”. When an insurance payer marks a denial with PR, they are indicating that the dollar amount associated with that adjustment is now the liability of the patient. Unlike CO (Contractual Obligation) denials, which usually must be written off by the healthcare provider, a PR denial technically allows the healthcare provider or practice to bill the patient for the balance.
However, billing the patient immediately upon receiving a PR 227 is rarely the best strategic move. The claim hasn’t been denied because the service isn’t covered; it has been denied because the payer is waiting for answers. If those answers are provided, the claim can be paid.
An important point to note here is that denial code PR 227 is rarely a standalone explanation. As written in the definition, the code is accompanied by a Remittance Advice Remark Code (RARC) as well. The RARC tells you specifically what information is missing. For example, you might see PR 227 paired with:
- MA64: Our records indicate that we are the third to pay for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.
- N245: Incomplete/invalid plan information for other insurance.
What Causes the PR 227 Denial Code?
Denial code 227 is almost exclusively triggered by Coordination of Benefits (COB) issues or accident liability questions. Payers are businesses, and they want to ensure they are the primary obligor before they release funds. If they suspect another party should pay first, they stop processing until the patient clarifies the situation.
When a baby is born, parents have a window (usually 30 days) to add the child to their policy. Sometimes, the insurance company requires a Social Security Number or a birth certificate to finalize the enrollment. Until that data is received from the parent, claims may be rejected with 227.
How to Prevent PR 227 Denial Code?
Since denial code PR 227 is mainly related to patient data, you must pay attention to details while filing claims. The following are some ways you can minimize the risk of PR 227 denials:
Proactive Front-Desk Data Collection
Prevention starts at registration. Your front-desk staff should be trained to ask specific COB questions, not just “Is your insurance the same?”
- Ask: “Do you have any secondary coverage?”
- Ask: “Is this visit related to a car accident or an injury at work?”
- Ask: “Have you received any letters from your insurance company recently requesting information?”
Wise Use of Eligibility Portals
Many payer portals now display COB alerts during the eligibility check. If you see a flag stating “COB Update Needed” or “Other Insurance on File,” advise the patient immediately before they see the physician. Tell them, “Your insurance shows a hold because they need you to update your other insurance information. Please call them right now so your visit today will be covered.”
Patient Education
Patients often do not understand the implications of ignoring insurance mail. A simple flyer at the checkout desk or a note on your website explaining the importance of responding to “Coordination of Benefits” letters can reduce these denials.
How to Resolve Denial Code 227?
Denials are inevitable. However, knowing the correct way to deal with them can save you from a lot of hassle. If you are ever faced with denial code 227, you can take the following approach:
Step 1: Analyze the Remark Codes
Look at the RARC. Is the payer asking for accident details? Other insurance updates? Student status? Knowing exactly what is missing allows you to guide the patient.
Step 2: Engage the Patient
Contact the patient immediately. Explain clearly: “Your insurance company has denied your bill because they need information from you that only you can provide. We cannot fix this for you.”
Provide them with the customer service number on the back of their card and the specific department they must contact.
Step 3: Bill the Patient (As a Last Resort)
If the patient refuses to cooperate after reasonable attempts (usually 30-45 days), you should shift the payment responsibility to the patient. Send a statement with a clear message: “Your insurance denied this claim because you failed to provide the requested information. The balance is now your responsibility.” Often, receiving a bill prompts the patient to finally call their insurer to resolve the issue.
Step 4: Get Denial Management Services
For larger practices, a high volume of PR 227 denial codes can be overwhelming. This is where professional denial management services can add value. Outsourced billing companies have the experience and expertise to deal with denials efficiently. Additionally, getting these services greatly reduces the administrative burden on your team.
Final Word
Let’s conclude this guide. PR 227 denial code is one of the most common reasons for claim rejections. It indicates that the payer rejected the claim because the patient information on the claim was insufficient. Also, the “PR” indicates that, in this case, the patient is responsible for the payment.
Denials can be frustrating to manage. That’s why it is better to let professionals like NeuraBill handle medical billing and revenue cycle management.
