As an expert in medical billing, understanding the nuances of various denial codes is crucial for efficient claims management. PR 27 denial code that indicates that the coverage was terminated at the time the service was provided. This denial is often received when the insurance policy was not active on the date of service (DOS) due to reasons such as non-payment of premiums, change in employment, or policy cancellation.
Here’s an example to explain a PR-27 denial scenario:
Case: A patient, John Doe, visited a healthcare provider for a routine check-up on March 15, 2023. The medical office billed the insurance company for the services provided.
Billing Details:
- Patient Name: John Doe
- Date of Service: March 15, 2023
- Service Provided: Routine Check-up
- Billed Amount: $200
Denial Received:
- Denial Code: PR 27
- Denial Reason: Coverage Terminated
- Denial Date: April 1, 2023
Explanation: Upon reviewing the denial, it was discovered that John Doe’s insurance policy was terminated on February 28, 2023, due to non-payment of premiums. Since the policy was not active on the date of the service (March 15, 2023), the insurance company denied the claim with PR 27, indicating that the coverage had been terminated.
Action Steps: To resolve this, the medical office would need to:
- Contact the patient to inform them of the denial and the reason for it.
- Verify if the patient had obtained new insurance since the termination of the previous policy.
- If new insurance is in place, re-bill the service to the new insurer with the correct policy details.
- If there is no new insurance, the patient would be responsible for the payment, and an invoice should be sent to them for the services rendered.
Preventative Measures:
- Always verify insurance coverage and active policy dates before providing services.
- Maintain regular communication with patients regarding their insurance status.
- Implement a system to check for policy updates or changes prior to appointments.
Understanding and effectively managing denial codes like PR 27 is vital in medical billing to minimize revenue loss and ensure timely reimbursement for services rendered.
What is the Denial Code PR 27 ?
PR27 denial code can be defined as the claims which will be denied by the insurance service providers with denial code PR27 as
“PR27 Denial – Expenses incurred after coverage terminated“
PR-27 Denial Code
This takes place right after the health care services are offered by the health care provider to the patients, in case, if the medicare coverage has already expired.
In other words, it means “the provider has performed the health care services to the patient after the insurance policy has been terminated.”
What to do if you have received a PR27 Denial Code?
In case you have received the denial code PR 27 , one can follow the steps mentioned below in order to resolve the issue.
- Step 1: Check eligibility
The first thing you can do is check the eligibility using the insurance provider’s website to find out if the policy is effective and also verify the termination date.
If you have trouble searching the right website, then you have to call insurance company’s customer service department as well and verify the eligibility of Insurance. Also ask for another insurance availability in case of 1st insurance termination.
- Step 2: Status of patient policy
Once the eligibility has been checked, then you need to check the status of the patient’s policy to ensure it was still active during the time of service offered. After which you can return to the process of reclaiming.
- Step 3: Update and file claim
If you find the insurance to be active at the time of service provided, then make sure to update and file the reclaim. Also can ask the representative for reprocess the claim.
In case if the policy is found inactive at the time of the service offered and no other insurance is active of date of service, then claim should billed to pat if instructions from client otherwise needs to follow the SOP.
Frequently Asked Questions- FAQs
Ans. In order to resolve the Denial code PR 27, you must know the date of receipt and denial of the claims.
This can be found out by contacting the claim department and then, resolving the code in case of any discrepancies.
Ans. The providers who have EDI enrollment agreements in place can have the access to use this eligibility checker tool. So in order to check the eligibility through eServices make sure to get yourself registered with an authorized insurance provider first.
Also, it is to inform you that only one provider administrator per EDI enrollment agreement / per PTAN / NPI combination would perform the registration process.
Ans. The PR in the PR 27 denial code stands for Patient Responsibility. A patient could be billed for this denial, however, it is important to make sure that there are no other rejection reasons that are specified in the EOB.
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