Denial Code PR-272
Coverage/program guidelines were not met.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-272 means
The service didn't meet the payer's coverage or program guidelines, reported under the patient-responsibility group. Verify whether the guideline was genuinely unmet — and whether the patient was properly notified — before treating the balance as theirs.
Why PR-272 happens
- A coverage criterion or program requirement wasn't satisfied as billed
- A preventive/screening service outside its covered frequency or age window
- Medical-policy criteria not met or not documented
- The patient elected a service that didn't meet guidelines, on notice
What to do when you get PR-272
- 1Read the paired remark and pull the payer's coverage policy/program guideline
- 2Confirm which guideline element wasn't met and whether your documentation actually meets it
- 3If the documentation meets the guideline, appeal or submit a corrected claim
- 4If the guideline truly wasn't met and the patient was notified, bill the patient
Got this denial right now?
Ask D3 whether to appeal or correct PR-272
PR-272 can go either way depending on the claim. Ask D3 tells you whether to appeal, correct, or just confirm status — free.
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-272?
PR-272 can be a coverage fight or a patient balance. If the record shows the guideline was met (or a covered alternative applies), appeal or correct rather than bill the patient. If the guideline genuinely wasn't met and the patient was notified in advance, the balance is the patient's. Don't bill the patient without confirming valid notice where the service was discretionary.
Timing & deadlines
If appealing, use the payer's window (Medicare-related plans 120 days for redetermination; commercial ~180 days from the remittance). Corrected claims follow timely-filing limits (~90-180 days commercial; Medicare 12 months from date of service).
Example
A screening billed outside its covered frequency returns PR-272. If the patient actually qualifies (e.g., a high-risk indication), a corrected claim or appeal supports payment; if the frequency limit truly applies and the patient was on notice, the balance is theirs.
Prevent PR-272 going forward
- Check coverage policies/program guidelines before discretionary services
- Verify frequency and age windows for preventive/screening care
- Give patients advance notice when a service may not meet guidelines
- Map services to their guideline requirements in your workflow
Code families most affected
- Preventive and screening services with coverage rules
- Policy-gated diagnostics and procedures
- Program-specific covered services
Related codes
Payer notes
CARC 272 ('guidelines not met') appears as CO-272 (provider liability) or PR-272 (patient liability) depending on the group code. The PR variant still warrants verifying the guideline and the patient's notice before billing.
Not sure how to work PR-272?
Ask D3 whether PR-272 should be appealed, corrected, or simply confirmed — free, backed by CMS, Medicare, and major-payer data.
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.