Denial code · group PR
PR-31: The payer cannot match the patient on the claim to any member it covers
Short answer
PR-31 means the payer could not find the patient in its membership from the name, date of birth, member ID and subscriber details on the claim. Despite the PR group, it is almost never a real patient balance; it is a data problem or a wrong-payer problem. Check the identifiers against the current card and the eligibility response, then send the claim again corrected, or send it to the right payer.
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.
Remark codes that usually come with PR-31
- MA36
- The patient's name is missing, incomplete or not valid
- N382
- The patient identifier on the claim, such as the member ID, is missing, incomplete or not valid
- MA61
- The patient's Social Security number is missing, incomplete or not valid
Common causes
A typo in the member ID, name or date of birth
A transposed digit, a letter O for a zero, a hyphenated surname entered as one word, a nickname instead of the legal name, or a date of birth keyed as the subscriber's. The payer matches on exact fields and stops at the first mismatch.
The patient is a dependent but was billed as the subscriber
The claim shows the child or spouse as the insured, with their own details in the subscriber loop, when the payer's record lists the parent or spouse as the subscriber and the patient as a dependent. The relationship code and subscriber information have to match the payer's file.
The payer reissued member IDs and the old one is still on file
Insurers change ID formats, move members to new plan products and issue new cards. The registration record still holds the number from the previous card, and the payer no longer recognizes it.
The claim went to the wrong payer or payer ID
A Medicare Advantage plan billed as Original Medicare, a Medicaid managed care plan billed as the state, or a plan within a large insurer family routed to the wrong payer ID. The payer that received the claim has never heard of the patient.
A newborn or new enrollee is not yet on the payer's file
A newborn billed under their own name before the plan has added them, or a new employee whose enrollment has not yet loaded, cannot be found even though coverage will exist once the file updates.
How to fix it and resubmit
- 1
Run a 270/271 eligibility check with the card in hand
Enter the details from the current card and compare the 271 response to the claim field by field: name spelling, date of birth, member ID, subscriber and relationship. Use the payer's version of each field on the corrected claim.
- 2
Resubmit with the corrected identifiers
Many payers treat PR-31 as a claim that never matched a member, so a new claim with the right details is accepted; others want a corrected claim with frequency code 7. Follow the payer's rule, and keep the original acceptance report for timely filing.
- 3
Send the claim to the right payer when the patient is not theirs
If eligibility shows coverage under a different plan or payer ID, bill that payer inside its filing window and attach the PR-31 remittance as proof of the original filing date.
- 4
Hold newborn and new enrollee claims until the file loads
Confirm with the payer when the member will appear, then bill with the correct subscriber and dependent details. Resubmitting before the file updates produces the same PR-31.
- 5
Call when every field already matches
If the card, the 271 and the claim all agree and the payer still cannot find the patient, call provider services with the claim number and the card details. Ask the representative to look up the member record and tell you what differs.
How to prevent it
- Eligibility verification before every visit, with the 271 response's name, date of birth, member ID and subscriber details copied into the registration record rather than typed from the card
- Both sides of the current card scanned at each visit and compared with the record on file, especially after the plan year changes
- Relationship to subscriber captured from the card and the eligibility response, not from the patient's description of the household
- Scrubber edits for each payer's member ID format and payer ID, so a wrong-length ID or a wrong payer is caught before submission
A PR-31 from a transposed member ID
An urgent care front desk keys a member ID from a photo of a card and transposes two digits. The claim returns PR-31 with N382. The biller runs an eligibility check with the card details, finds the correct ID on the 271 response, corrects the registration record and resubmits the claim as a new claim, which the payer accepts. The center now imports the 271 fields into the record instead of keying them. 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-31
Should I bill the patient for a PR-31?
Why is this code PR and not CO?
Corrected claim or new claim after a PR-31?
What is the difference between PR-31 and PR-27?
How should I bill a newborn whose plan has not added them yet?
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