PR 27 Denial Code | Reasons, Prevention, And Solutions

Understanding the aspects of medical billing is crucial for healthcare providers to ensure a smooth revenue cycle. One common hurdle in this process is encountering denials and most common of them is Denial code PR 27. Here in this guide, we will delve into the reasons behind PR 27 denial Code, explore strategies to avoid them, and provide effective solutions to navigate through these challenges.

PR 27 Denial Code

PR 27 Denial Code

The PR 27 Denial Code used in medical billing that signifies an issue related to the patient’s eligibility for the claimed service. Insurances describe this denial with its description “expenses incurred after patient’s insurance coverage terminated”. Which indicates that the patient has no active insurance for the Date of Service you billed a claim.

Reasons for PR 27 or CO 27 Denial?

Expired Insurance Coverage:

The reason behind the denial code PR 27 is that the members insurance coverage have expired before service was rendered. When claims are billed with inactive member insurance then insurance denied the claims with reason code CO-27 OR PR-27.

Denial Code ST

Some Insurances use the Denial Code ST instead of PR27 or CO27. But the reason is same in all the cases which is “Claimant not effective or terminated for this date of services”.

How to Avoid PR 27 Denial?

As we have already mentioned above that Denial Code PR 27 is one of the most common denial code this cause a delay in payments. To avoid this type of denials and other denials we have listed some of the useful tips for your healthy Revenue Cycle Management.

  • Verify Insurance Eligibility:
    Prior to providing services, verify the patient’s insurance eligibility to ensure coverage is active on the date of service. You can also get the Best Eligibility & Benefits Services from us on affordable rates
  • Accurate Patient Information:
    Double-check and maintain accurate patient information to avoid disagreement that could lead to other denials.
  • Check Coverage Policies:
    Understand the patient’s insurance coverage policies to ensure the billed service is covered.
  • Implement Robust Eligibility Checks:
    Integrate a robust eligibility verification process into your billing system to catch potential issues before claims are submitted.
  • Train Staff:
    Ensure that your staff is well-trained in insurance verification processes to minimize errors. Also avoid common pitfalls leading to PR 27 denials.

Check Out: BCBS Prefix Lookup 2024

Solutions for PR 27 Denial

Following actions are helpful for you if you have received a CO 27 denial code from insurance.

  • Verify Members Eligibility:

If you have received a denial code PR 27 at first you need to Verify Members Eligibility through insurance web portal or you can call to insurance benefits & eligibility department to verify the member policy active for the date of service you are calling.

  • Coordinate with Payers

Upon Verification of eligibility through Insurance web portal if the members plan is active then simply resubmit claim to the insurance company or call to insurance for claim status and ask the representative to reprocess this claim. Or if you verified eligibility on live call then ask then give the claim details to the same representative and request her to send back this claim for reprocessing.

But In case, if you found that member insurance is terminated or inactive for the Date of Service you are looking for then you need to check patient demographics to find if there is any other active insurance policy member have or not!

  • Coordinate with Member

If failed to find other active insurance plan for the Date of service then call the patient for active insurance info and bill the claim to active insurance accordingly. If patient has no active insurance and cannot pick up a call then you have right to send a bill to patient.

  • Appeal the Denial:

In case, denial is based on incorrect information and insurance representative refused to reprocess the claim. Then submit a well-documented appeal with accurate details to challenge the decision.

How to Discuss PR 27 Denial Code With Insurance Representative On Call?

Regarding PR 27 Denial if you want to talk to insurance representative on call follow this prompt. When a call is connected to Live rep, after providing patient info to rep ask about:

  • First of all, ask for the general claim status and get the claims info.
  • Now ask the representative to check the members eligibility for the Date of Service you have PR 27 Denial. If policy is active on Date of Service, then tell the representative that claim processed incorrectly and denial isn’t correct. Request them to review and reprocess the claim.
  • If insurance policy is terminated for the Date of Service, then ask the representative to check is there any other active insurance plan on file for this Date of Service on their records. If found, ask for that insurance ID number and plan name and submit the claim to members active insurance.

Conclusion:

In conclusion, understanding the intricacies of PR 27 denials is crucial for healthcare providers to optimize their revenue cycle. By proactively addressing eligibility issues, maintaining accurate patient information, and collaborating effectively with payers providers can navigate the complexities of medical billing and minimize the impact of PR 27 denials on their financial health. Check out Rapid Billing Solution for more information regarding medical billing.

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