Decoding Denials for Healthcare RCM Teams
For RCM teams, understanding the significance of unique denial codes is crucial. Denial codes serve as key indicators that offer insight into the reason why claims are getting rejected. Each code represents a specific reason as to why claims are getting denied, and knowing what these codes represent can be a key differentiator in recovering the revenue you deserve. The ability to decipher denial codes is essential for pinpointing operational inefficiencies, securing revenue, and ensuring optimal financial performance. If RCM leaders can quickly identify and understand denial codes, they can efficiently implement targeted strategies to streamline processes and optimize their revenue cycle.
As a part of our Decoding Denials blog series, we’ll be identifying and decoding common denial codes and outlining ways that teams can prevent or respond to each code. In this blog, we’re going to decode the denial code PR-27. Let’s get into it!
What is Denial Code PR-27
Definition: Denial Code PR-27 means that the claim was denied because the expenses were incurred after coverage ended.
Common Cause of Denial Code PR-27
Cause: Denial Code PR-27 can occur as a result of multiple different mishaps. These can include:
- Lack of coverage verification
- Miscommunication with patient
- Delay in claim submission
- Outdated patient insurance information on file
- Billing errors, such as typos or missing information
Example: Let’s look at a real-life example. John has health insurance through his job, he is leaving his job this month, so his insurance expires at the end of the month. He is taking a few weeks off in between jobs, so his new coverage won’t kick in for another month. If John goes to the doctor for an appointment in between jobs and submits his expired insurance information, the claim will get denied because his expenses were incurred after his insurance coverage has ended.
Responsibility: In this case, the portion of the code that says “PR” refers to the fact that it is the Patient’s Responsibility. If we look at the same example above, John is the one responsible here because he went in for his appointment when he was no longer covered by his insurance.
Ways to Mitigate Denial Code PR-27
Prevention: Denial Code PR-27 can easily be avoided by taking precautions to ensure patient data is accurate and up to date. These precautions can include:
- Timely submission of claims
- Clear communication with patient
- Coverage verification ahead of providing care
- Automation to verify claim accuracy
- Staying updated with payer updates and changes
Example: This denial code is one reason why eligibility checks are so important. Prior to John’s appointment, the provider should run an eligibility check with John’s insurance to make sure he is eligible for the services to be rendered. If eligibility checks are run correctly and on time, this denial can be avoided because the team will find out that John is no longer covered by his insurance. This will mean that John will either have to pay for his services up front and out of pocket, or wait until he is properly covered to get care.
How to Address Denial Code PR-27
Response: If you receive Denial Code PR-27, there are a few steps you can take to uncover and address the root of the problem. First, review the date that the patient’s coverage ended. This will give you insight into whether the denial was caused by insurance expiration or an error in the claim. From there, you can proceed in a few ways.
- If the denial is due to an error, you can appeal the claim.
- If the denial is due to incorrect or expired insurance information, communicate with the patient to see if they have updated insurance information or if they lack coverage entirely.
- If the patient has no coverage, work with them to sort out a payment method and/or plan.
How Adonis Can Help
Verifying patient eligibility is a critical step in ensuring accurate and timely revenue outcomes. By confirming a patient's eligibility prior to providing services, healthcare organizations can avoid costly claim denials and reduce the risk of non-payment. Adonis automates the time-consuming process of verifying a patient's insurance coverage and benefits to ensure that the services being provided are covered under the patient's plan. With Adonis’ automations for patient eligibility, teams can avoid Denial Code PR-27.
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