Denial Code PR-27
Expenses incurred after coverage terminated.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-27 means
The service was provided after the patient's coverage ended, so the plan won't pay and the balance is the patient's. The key is confirming the actual termination date before billing the patient.
Why PR-27 happens
- The patient's policy terminated before the date of service
- Employment ended and coverage lapsed (without continued COBRA)
- A plan change moved the patient to a different carrier on the date of service
- Stale eligibility on file showed coverage that had already ended
What to do when you get PR-27
- 1Verify the exact coverage termination date against the date of service
- 2Check whether the patient had other/replacement coverage (e.g., a new plan or COBRA) on that date
- 3If another plan was active, refile to the correct payer
- 4If coverage truly ended and no other plan applies, bill the patient
Got this denial right now?
Generate a patient-balance explainer letter — free
PR-27 is the patient's responsibility. Generate a clear, plain-English balance letter — free, no signup.
PR group code: who absorbs the charge
Patient Responsibility — May be billed to the patient.
A PR adjustment is the patient's liability — a deductible, coinsurance, copay, or a non-covered amount the patient owes. It is collectible directly from the patient, ideally after advance notice for any non-covered service.
Appeal, correct, or write off PR-27?
PR-27 is usually correct when coverage genuinely ended — the balance is the patient's. First rule out a fixable cause: a wrong termination date, retroactive reinstatement, or replacement coverage that should be billed instead. Appeal only if the patient was actually covered on the date of service and the payer's termination date is wrong; otherwise refile to the correct payer or bill the patient.
Timing & deadlines
If refiling to a replacement payer, mind that payer's timely-filing limit (~90-180 days commercial; Medicare 12 months from date of service). There is no payer deadline on collecting a legitimate PR balance from the patient.
Example
A patient is seen on the 5th, but their plan terminated on the 1st. The payer returns PR-27 (expenses after coverage terminated). If the patient started a new plan on the 1st, refile there; if not, the visit is the patient's responsibility.
Prevent PR-27 going forward
- Run electronic eligibility before every date of service, including termination dates
- Ask patients about recent job or plan changes at check-in
- Capture replacement coverage when a plan ends
- Re-verify coverage for patients returning after a gap
Code families most affected
- Services around coverage-termination dates
- Patients with recent employment/plan changes
- Claims where replacement coverage may apply
Related codes
Payer notes
PR-27 (after coverage terminated) and PR-200 (during a lapse in coverage) both land the balance on the patient once you confirm no other coverage applies. Verify the termination date and any replacement plan before billing the patient.
Explain this PR-27 balance to your patient
PR-27 is a patient-responsibility balance. D3rx drafts a clear, plain-English patient-balance explainer for PR-27 — free, no signup.
Medical billing disclaimer
CARC/RARC definitions are the standardized X12 set; group-code semantics follow the X12 Claim Adjustment Group Code standard. Filing and appeal windows vary by payer — the standard anchors shown (Medicare redetermination 120 days from the remittance; Medicare timely filing 12 months from date of service; most commercial payers ~90-180 days) are general references, not a guarantee for any specific plan. Always confirm the rule in the payer's provider manual before acting. D3rx is not responsible for claim outcomes.