Denial code · group PR
PR-27: The patient's coverage with this payer had ended before the date of service
Short answer
PR-27 means the payer's records show the patient's coverage ended before the date of service, so it owes nothing and the charge becomes patient responsibility. Before billing the patient, check whether another plan was active that day; many patients who lose one plan have another, and a retroactive termination is sometimes reversed. If no plan covered the date, the patient owes the charge under your self-pay policy.
Look up other codes in the denial code library.
Last reviewed by the Remitwright billing team. Editorial policy
Group PR means patient responsibility: the balance may be billed to the patient. The number is the reason; the two-letter group says who carries the balance.
Common causes
The patient changed plans and nobody re-ran eligibility
A new job, a new Marketplace plan, a move from Original Medicare to a Medicare Advantage plan or back, and the practice kept billing the payer on the card from last year. The old payer is right; coverage ended.
The coverage was terminated retroactively
An employer stopped paying premiums, a Marketplace plan lapsed for non-payment, or a Medicaid redetermination ended eligibility with an effective date already in the past. The eligibility check before the visit showed active coverage; the payer later changed it.
The patient aged off a parent's plan or lost dependent status
Dependents reach the plan's age limit, divorces end spousal coverage, and students lose student plans. The patient may not have realized the change had taken effect.
The payer's record is wrong
A COBRA election not yet processed, a reinstatement after a premium catch-up that has not posted, or an employer file sent late can show as terminated when the patient is in fact covered. The patient's employer or the plan has to correct it.
A recurring service kept billing past the end date
ABA sessions, home care visits, therapy plans and monthly DME rentals bill in cycles. One eligibility check at the start of care, with no monthly re-check, means weeks of claims go to a payer that has already closed the file.
How to fix it and resubmit
- 1
Run eligibility for the date of service across every known payer
Check the billed payer for the exact termination date, then check any other payer on record and ask the patient for a current card. A 271 response that shows an active plan on the date of service changes the whole route.
- 2
Bill the correct payer inside its timely filing window
Send the claim to the active plan with the required data, and keep the PR-27 remittance; many payers accept another payer's denial as proof the claim was filed on time when the wrong payer was billed first.
- 3
Ask about reinstatement when the termination was retroactive
Call the payer for the termination reason and whether a reinstatement is pending. For Medicaid, check the state eligibility system; eligibility is sometimes restored back to the termination date after a redetermination appeal, and the claim can then be resubmitted.
- 4
Tell the patient what you found and what happens next
Explain that the payer shows coverage ended on a given date and ask whether the patient has a new plan, a pending reinstatement or COBRA. A patient who sorts out their coverage turns a self-pay balance back into a payable claim.
- 5
Bill the patient as self-pay only when no coverage existed
PR-27 puts the balance on the patient, and if no plan covered the date, the patient owes the charge at your self-pay rate under your financial policy. Send the statement with the payer's explanation and offer the payment options you have.
How to prevent it
- Eligibility verification before every visit, not just at the first one, with the 271 response stored on the account
- Monthly re-verification for recurring services such as ABA, home care, therapy plans and DME rentals, with a report of accounts whose coverage shows an end date
- Re-verification of every patient at the start of the plan year and after state Medicaid redetermination dates
- Front desk capture of the current card at each visit, with the plan name, member ID and effective date compared to the record
A PR-27 on a month of ABA sessions after a job change
An ABA provider bills a month of sessions and every claim returns PR-27. The eligibility check before the month showed active coverage, but the child's parent changed employers mid-month and the old plan ended on the last day of employment. The provider gets the new card, verifies the new plan for each session date, and sends the sessions after the change date to the new plan, which requires its own authorization; a retro-authorization request is filed citing the coverage change. Sessions before the change go back to the old plan with the correct dates. This is a hypothetical example.
Official text: the X12 claim adjustment reason code list. The meaning above is our paraphrase for billers; the list is the authority.
FAQ
Questions about PR-27
Can I bill the patient as soon as I see PR-27?
The coverage was terminated after my eligibility check showed it active. Can I appeal?
A Medicaid patient lost coverage. Is there anything to do?
Does the PR-27 denial help with timely filing at the new payer?
What is the difference between PR-27 and PR-31?
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