Denial Code PR-288
Referral absent.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-288 means
A required referral wasn't on file, reported under the patient-responsibility group — often because the patient went to a specialist without the plan's required referral. Check whether a referral can still be obtained before treating the balance as the patient's.
Why PR-288 happens
- The patient saw a specialist without the required PCP referral
- A referral exists but wasn't submitted to or recorded by the plan
- The referral expired before the date of service
- The patient bypassed the plan's referral/gatekeeping process
What to do when you get PR-288
- 1Check whether a valid referral exists or can be obtained retroactively
- 2If a referral existed but wasn't recorded, submit it and resubmit the claim
- 3If it was genuinely missed, request a retroactive referral from the PCP where the plan allows
- 4If no referral is possible and the patient bypassed the process, bill the patient after notice
Got this denial right now?
Ask D3 whether to appeal or correct PR-288
PR-288 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-288?
PR-288 sits between a recoverable referral issue and a patient balance. If a referral existed or can be obtained retroactively, pursue that — a corrected claim or retro-referral beats billing the patient. If the patient knowingly bypassed the referral process and no retro-referral is available, the balance is the patient's. Confirm emergency/urgent-care protections, which often waive referral requirements.
Timing & deadlines
Retro-referral and appeal windows are short and payer-specific — act within days. Standard anchors apply (Medicare redetermination 120 days from the remittance; commercial ~180 days). There's no payer deadline on a legitimate PR balance once referral options are exhausted.
Example
A gatekeeper-plan member sees a specialist without a referral, and the claim returns PR-288 (referral absent). If the PCP will issue a retroactive referral, payment is recoverable; if not and the patient bypassed the process, the balance falls to the patient.
Prevent PR-288 going forward
- Verify a valid referral is on file before gatekeeper-plan specialty visits
- Confirm the referral covers the provider, service, and date span
- Track referral expiration dates
- Inform patients of cost exposure when they self-refer without a referral
Code families most affected
- Specialist services on gatekeeper/HMO plans
- Referral-gated diagnostics and procedures
- Member self-referrals without a referral on file
Related codes
Payer notes
CARC 288 ('referral absent') carries CO or PR by liability: CO-288 is provider/contractual; PR-288 shifts the balance to the patient (e.g., a knowing self-referral). Referral issues are often recoverable retroactively — exhaust that before billing the patient.
Not sure how to work PR-288?
Ask D3 whether PR-288 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.