Denial Code PR 119 | Maximum Benefit Met Denial (2022)

Denial code PR 119 means in medical billing is a benefit for the patient has been reached the maximum for this time period or occurrence has been reached.

Maximum benefit met means services provided to the patient have been exhausted in terms of money or visits.

Medicare has specific instructions for certain services, like lab services or preventive care. Medicare provided utilization guidelines that do not allow the services to be covered if they are performed within a specific time frame after the previous service.

How to handle Maximum Benefit Met (PR 119) Denial:

In denial handling or AR-followup when received the maximum benefit is met  (Denial code PR 119), just have to check on the web portal what benefits are covered by insurance and if the patient already has taken the benefits in that case claim should be transferred to secondary insurance.

Denial Code PR 119 AR-Followup Steps:

When receive the denial code PR119 as the Maximum benefit met by pat and not able to find information on the web portal then call insurance and following steps should be followed while connecting with the insurance rep as below

1- First ask for the claim number and denial date and then ask the rep in which terms the maximum benefit reached

A– In terms of the dollar amount or money 

B– Or in terms of visits. Are visits reached the maximum as per allowed by the insurance plan?  

2- How much dollar amount patient already met to exclude this claim?

A- If the rep says the dollar amount has been reached at maximum by the patient so ask call reff number and the claim should transfer to sec ins.

B- If the rep says not met then request her/him to send a claim for reprocessing. Also, ask the food call reff number and how much time it will take to reprocess the claim.

Both steps are also followed if the patient maximum benefit is met (denial code pr 119) in terms of visits. If visits are already met then the claim should transfer to sec or transfer to pat if no sec ins. If not met claim send for reprocessing.

Notes- 

  • While the claim is billed to secondary insurance, do not change the payer sequence. Eg – Do not make secondary insurance as primary.
  • If there is no other payer is active as secondary ins transfer it to the patient.
  • Before billing to a Secondary need to verify the eligibility of the secondary insurance.

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