Denial Code PR-275
Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-275 means
A secondary payer isn't covering the patient-responsibility amounts (deductible, coinsurance, copay) left by the primary payer, so those amounts remain the patient's to pay. It's common when the secondary plan doesn't pick up the primary's cost-share.
Why PR-275 happens
- The secondary plan doesn't cover the deductible/coinsurance/copay the primary assigned
- The primary's patient-responsibility amounts exceed what the secondary will pay
- A secondary plan with limited cost-share coverage (not a true Medigap fill)
- Coordination leaves a residual patient balance after both payers
What to do when you get PR-275
- 1Reconcile the primary EOB's patient-responsibility amounts with the secondary's adjudication
- 2Confirm the secondary truly doesn't cover those cost-share amounts (vs. a COB/setup error)
- 3If the secondary should have paid them, resubmit the primary EOB and request reprocessing
- 4If the secondary legitimately doesn't cover them, bill the patient for the residual
Got this denial right now?
Generate a patient-balance explainer letter — free
PR-275 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-275?
PR-275 is usually correct — the secondary simply doesn't cover the primary's cost-share, leaving it with the patient. First rule out a COB/setup error: if the secondary should have paid the deductible/coinsurance and didn't, re-send the primary EOB and request reprocessing. If the secondary genuinely doesn't cover the primary's patient responsibility, bill the patient for the residual.
Timing & deadlines
If requesting secondary reprocessing, mind the secondary's timely-filing window (often measured from the primary EOB date; commonly ~90-180 days commercial, 12 months Medicare). There is no payer deadline on the residual PR balance owed by the patient.
Example
A primary payer applies $150 to the patient's deductible, and the secondary plan — which doesn't cover deductibles — returns PR-275 on that amount. Confirming the secondary's benefit and billing the patient the $150 resolves it.
Prevent PR-275 going forward
- Verify what cost-share amounts the secondary plan actually covers during eligibility
- Attach the primary EOB/ERA to every secondary claim
- Reconcile secondary payments against the primary's patient-responsibility lines
- Set patient expectations when a secondary won't cover the primary's cost-share
Code families most affected
- Secondary/COB claims with residual cost-share
- Patients with limited secondary coverage
- Deductible/coinsurance/copay balances after two payers
Related codes
Payer notes
PR-275 is used with the PR group code by design — it specifically assigns the prior payer's deductible/coinsurance/copay to the patient when the secondary doesn't cover it. Distinguish a true non-coverage from a COB setup error before billing the patient.
Explain this PR-275 balance to your patient
PR-275 is a patient-responsibility balance. D3rx drafts a clear, plain-English patient-balance explainer for PR-275 — 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.