PR-100 Denial Code: The payer sent the payment to the patient
The plan issued this claim's money directly to the patient, insured, or responsible party instead of your practice. The balance becomes the patient's to pay you.
- Group code
- PR - Patient Responsibility
- Code type
- CARC
- Billable to patient?
- Yes - the patient received the funds
- Appealable?
- No - bill the patient
- Category
- Patient Responsibility
- Common pairing
- MA28
CAS*PR*100*125.00On a paper EOB it shows as PR-100.What PR-100 means
PR-100 is not a true denial - the claim was processed and paid, but the check went to the patient (or the policyholder or guarantor) rather than to the practice. This most often happens when the provider is out of network or no assignment of benefits is on file, so the plan follows its member-payment rules. Because it carries the PR group, the amount is patient responsibility: you bill the patient for the money the payer sent them. If you did accept assignment or hold a signed assignment-of-benefits, the payment was misdirected and the payer can be asked to reprocess it to you. Either way, act quickly - patients who receive insurance checks do not always realize the money belongs to the practice.
Common causes
- The provider is out of network and the plan pays members directly for out-of-network claims.
- No assignment of benefits was on file or transmitted with the claim.
- The claim went out without the accept-assignment indicator set, so the payer defaulted to paying the member.
- The patient filed the claim themselves, so the payer reimbursed them directly.
- The payer misread or ignored an assignment that was actually on file.
How to fix it
- Confirm from the remittance exactly how much was paid to the patient and on what date.
- Bill the patient promptly, with a statement that references the payer's payment to them so the ask is clear.
- If you accepted assignment or hold a signed assignment-of-benefits, send it to the payer and request the payment be redirected or the claim reprocessed.
- Offer a payment plan if the amount is large - the patient may have already spent the check.
- Document every contact attempt in case the balance moves to collections.
How to prevent it
- Collect a signed assignment-of-benefits from every patient at intake and transmit accept-assignment on every claim.
- Verify network status before rendering, and check how the patient's plan handles out-of-network payments.
- Tell out-of-network patients up front that any insurance check they receive is owed to the practice.
- Consider collecting deposits or payment at time of service for out-of-network patients.