Denials are frustrating for every biller. However, when a payer rejects a claim, saying the patient isn’t registered with us, it can confuse even the most experienced billers. This type of denial is often issued with the PR 31 Denial Code.
In this guide, we have simplified this denial for you. We will explain what PR 31 is, why it occurs, how you can prevent it, and some resolution steps that you can take to deal with this denial. So, let’s start.
PR 31 Denial Code – Description
PR 31 denial code is defined as:
“Patient cannot be identified as our insured.”
Let’s elaborate on this. As the definition explains, denial code 31 tells you the payer could not confidently identify the patient as an enrolled member for that claim. The emphasis here is on the code “PR”. PR means “patient responsibility”. It simply means that the insurance company does not recognize the patient and tells the healthcare provider that all payments are the patient’s responsibility.
If we look at Medicare specifically, this code appears on the claim when Medicare cannot identify the patient as insured. This mostly happens when the biller enters the wrong Medicare Beneficiary Identifier, or the patient does not have Part B entitlement, or the name on the claim simply doesn’t match the name on the Medicare card.
This is what makes PR 31 very frustrating to deal with. The service may be billable, medically necessary, and coded correctly, but due to minor mistakes, the claim is denied, usually because the payer cannot connect the patient data on the claim to the coverage record on file.
What Causes the PR 31 Denial Code?
Now that we have discussed what denial code PR 31 is, let’s discuss why it happens. Here are the top reasons:
Incorrect Patient Details
As we have already explained in the previous section, the most common and also the most logical reason is a simple mismatch between the patient identifiers on the claim and the insurance company’s enrollment file. Medicare, for instance, specifies the following three reasons as the most important causes of PR 31 denial code:
- Incorrect Medicare number.
- Lack of Medicare Part B entitlement.
- Names that do not match the Medicare card.
It is vital to note here that if the patient has two last names, a hyphenated surname, or a recent card update, even a minor formatting difference can break the payer match.
Timing Issue
A second cause is timing. Eligibility may be valid today, but not on the actual date of service. So, before submitting the claim, you must always make sure the date of service falls within the patient’s entitlement dates.
Incorrect Data Collection
Another big reason for denial code 31 is stale source data. Sometimes, your staff may get data from an old insurance card, an outdated registration record, or a payer file that contains an unresolved demographic issue, rather than the updated documents.
It is also the patient’s responsibility. If a patient finds an error on the Medicare card, they must immediately contact the Social Security Administration to correct the record.
Coordination of Benefits (COB)
Another common reason for PR 31 denials is billers getting confused by the coordination of benefits. If a patient is registered with multiple insurance payers, the billing can become complex.
Due to this complexity, billers may sometimes submit the claim to the wrong payer. This leads to the claims being rejected with PR 31.
How to Prevent Denial Code PR 31?
We have explained what denial code PR 31 is and why it happens. The next step is to explain how to prevent this denial. Here’s how:
Start with exact data capture, not “close enough” data capture. At the front desk, always collect the current insurance card from the patient. It doesn’t matter if he is new to your practice or a recurring patient. Keep a copy of his file, and note the member identifier exactly as it appears. For example, if the patient has Medicare insurance, you must note the beneficiary identifier, enter the patient’s first and last name in the proper order, character for character. If the name on the card has a hyphen, a suffix, or a dual surname, you should add it.
Next, verify eligibility for the actual date of service, not just for the month, and not just at the time of scheduling. A quick eligibility check before the visit is helpful, but a second review before claim submission catches changes that happen between appointment booking and billing. That one habit can prevent many PR 31 denials because it confirms both active coverage and the exact patient data the payer expects to receive.
Here is a checklist that you can give to your front desk staff:
- Confirm the spelling of the patient’s legal name.
- Ask whether a new insurance card was issued recently.
- Compare the subscriber number against the scanned card image.
- Verify plan-effective dates for the actual date of service.
How to Resolve Denial Code 31?
How would you resolve the PR 31 denial code? Is there any way to correct your mistakes? Well, the answer is Yes! If you are ever faced with denial code 31, you can take the following resolution steps:
Confirm the Denial Code on the Remittance Advice
Pull registration record + insurance card on file + submitted claim. Identify exact-match errors.
Verify Eligibility via the Payer Portal
Compare portal record to claim: identifier, legal name, DOB, entitlement dates, name formatting.
Correct and Resubmit as a New Claim
If the Medicare record is wrong, direct the patient to the Social Security Administration first.
Close the Loop Internally
Track where bad data entered the workflow (Scheduling? Front-desk? Scanning? Eligibility? Claim creation?). Root cause notes prevent recurrence.
Final Thoughts
We have reached the end of this guide. To sum up, let’s revisit the essential points from the blog.
- PR 31 is one of those denials that looks small on paper, but is expensive in practice. It occurs when the patient is not found as a beneficiary in the payer’s record.
- Root causes of the PR 31 denial code are incorrect patient details, timing issues, inaccurate data collection, and coordination of benefits issues.
- Resolution is possible. Just follow the steps mentioned in this guide to recover your reimbursement.
However, prevention and resolution are not always simple. We recommend getting professional denial management services from expert billing companies, like NeuraBill, to turn denials into dollars.
