Denial Code PR-279
Services not provided by Preferred network providers.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-279 means
The services were provided outside the plan's preferred (narrow) network, and under the PR group code the resulting balance is the patient's — typically because the patient chose a provider outside the member's preferred network.
Why PR-279 happens
- Care from a provider outside the plan's preferred/narrow network
- A tiered plan where non-preferred providers carry higher member cost
- The patient elected a non-preferred provider despite network limitations
- A provider not in the member's specific 'narrow' network tier
What to do when you get PR-279
- 1Confirm the provider's status relative to the patient's PREFERRED/narrow network (not just any network)
- 2Check whether No Surprises Act protections apply (emergency or certain facility-based care)
- 3If the provider was actually preferred-network but mis-tiered, correct/appeal instead of billing
- 4If the higher cost is a legitimate non-preferred choice, bill the patient after notice
Got this denial right now?
Generate a patient-balance explainer letter — free
PR-279 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-279?
PR-279 is collectible from the patient when they chose a non-preferred-network provider and the choice isn't legally protected. Verify the provider's preferred-network/tier status first — a mis-tiered preferred provider is an appeal, not a patient bill — and apply No Surprises Act protections to emergencies and certain facility-based services. Where the non-preferred choice was the patient's, bill the patient with advance notice.
Timing & deadlines
If appealing a network-tier error, use the payer's window (commercial ~180 days from the remittance). There is no payer deadline on a legitimate PR balance, but confirm surprise-billing protections before billing the patient.
Example
A tiered plan member sees a provider outside the preferred network, and the claim returns PR-279 for the higher non-preferred cost. If the choice was the patient's and not protected, the balance is theirs; if the provider was actually preferred-tier, the network record supports an appeal.
Prevent PR-279 going forward
- Verify preferred/narrow-network and tier status before scheduling
- Inform patients of higher costs for non-preferred providers in advance
- Apply No Surprises Act protections to emergency and facility-based care
- Keep network-tier data current per payer
Code families most affected
- Narrow-network and tiered-plan claims
- Non-preferred-provider services
- Member-elected out-of-preferred-network care
Related codes
Payer notes
PR-279 specifically concerns the PREFERRED (narrow) network and is close kin to PR-242 (network/PCP). Confirm the provider's preferred-tier status and any surprise-billing protections before billing the patient.
Explain this PR-279 balance to your patient
PR-279 is a patient-responsibility balance. D3rx drafts a clear, plain-English patient-balance explainer for PR-279 — 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.