PR-26: Expenses incurred prior to coverage.

Why it fires

• The patient's coverage effective date is after the date of service
• A waiting period applies before certain benefits become active
• Coverage was entered into the system with an incorrect, too-late effective date

Corrective actions, ranked

1. 1

   Verify the effective date

   Confirm the exact coverage start date on the payer's eligibility system.

2. 2

   Identify prior coverage

   Ask the patient what insurance, if any, was active on the actual date of service and rebill that payer.

3. 3

   Bill the patient if uninsured

   If no coverage existed on that date, move the balance to patient responsibility per your self-pay policy.

Is it worth appealing

Appeal only if you can show the effective date on file is wrong or coverage was retroactively extended to include this date of service.

Other denial codes to check

Codes that share a remark code with this one, or that are reported under the same group code.

• PR-204This service/equipment/drug is not covered under the patient's current benefit plan
• PR-50These are non-covered services because this is not deemed a 'medical necessity' by the payer.
• PR-151Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
• PR-96Non-covered charge(s).
• PR-1Deductible Amount
• PR-2Coinsurance Amount

See every CARC in the dataset