PR 27 Denial Code Explained: How to Avoid Claim Denials

Are you frustrated by PR 27 denials on your billing claims? In this post, we break down what PR 27 means and share practical tips to reduce these denials. At TexMed Billing Solutions, we help you overcome these challenges with our expert denial management services.

What Is the PR 27 Denial Code?

PR 27 stands for Patient Responsibility. This code appears on claims when the insurer decides not to cover certain healthcare services. In these cases, the cost falls on the patient. Essentially, if your claim is marked with PR 27, the insurance company is saying the expense must be paid out-of-pocket.

Common Reasons for PR 27 Denials

There are several reasons why claims get denied with a PR 27 code. Here are the most common ones:

• Outdated Patient Insurance Information:
  Patient details may have changed or expired. If you use old data, the claim is denied.
• Delays in Claim Submission:
  Claims must be submitted quickly. Late submissions may fall outside the coverage period.
• Lack of Coverage Verification:
  Not checking a patient’s current insurance can lead to claims for services not covered.
• Changes in Insurance Plans:
  If a patient switches providers without notifying you, you might bill the wrong plan.
• Billing Errors:
  Mistakes like wrong dates or incorrect coding can delay processing until the patient’s coverage ends.
• Incorrect or Missing Documentation:
  Claims need full, correct documentation. Missing or incomplete records can cause denials.
• Eligibility Issues:
  Some services are simply not covered under a patient’s plan.
• Coordination of Benefits (COB) Issues:
  If a patient has more than one policy and the claim is sent to the wrong insurer, it gets denied.
• Pre-Authorization Requirements:
  Some services need prior approval. Without it, the claim is rejected.
• Patient Responsibility:
  Costs like copayments and deductibles should be billed to patients, not insurers.

Strategies to Prevent PR 27 Denials

Here are actionable strategies to reduce PR 27 denials:

1. Regularly Update Patient Insurance Information

• Ask patients to confirm their insurance details at every visit.
• Use electronic verification tools to get real-time updates.

2. Timely Claim Submission

• Set internal deadlines that fall well within insurers’ filing limits.
• Automate claim submissions through your EHR system.

3. Thorough Coverage Verification

• Check insurance coverage before providing services.
• Train your staff to verify policy numbers, coverage dates, and pre-authorization needs.

4. Proactive Communication with Patients

• Remind patients to inform you about any changes in their insurance.
• Send appointment confirmations that include a checklist of insurance details.

5. Accurate Billing Practices

• Train your billing team on correct coding and documentation.
• Use billing software that checks for common errors.

6. Ensure Proper Documentation

• Standardize your documentation process using electronic health records.
• Verify that all required information is included with each claim.

7. Verify Eligibility for Services

• Confirm that the services provided are covered by the patient’s plan.
• Consult with insurers if there is any doubt about coverage.

8. Proper Coordination of Benefits (COB)

• Identify the primary and secondary insurers when patients have multiple policies.
• Keep detailed records to ensure claims go to the right insurer.

9. Obtain Pre-Authorizations

• Secure pre-authorizations for services that require them before care is given.
• Train staff to follow up with insurers for confirmation.

10. Address Patient Responsibility

• Clearly separate billing for services that patients must pay.
• Use patient portals for easy access to billing information and payments.

How TexMed Billing Solutions Can Help

At TexMed Billing Solutions, we understand the complexities of PR 27 denials. Our advanced AI driven processes, software and experienced professionals work together to:

• Verify patient insurance details accurately.
• Ensure timely and error-free claim submissions.
• Obtain necessary pre-authorizations.
• Educate patients on their financial responsibilities.

By handling these crucial steps, we reduce claim denials and improve your revenue cycle. Our proactive approach minimizes surprises and protects your practice’s financial health.

Contact us at support@texmed.us to know more.

The Bottom Line

Understanding PR 27 denials is key to reducing financial losses. By regularly updating patient information, verifying coverage, and ensuring accurate billing, you can prevent these denials. Contact TexMed Billing Solutions today to learn how our services can streamline your revenue cycle and keep your practice running smoothly.