Denial Code PR-31
Patient cannot be identified as our insured.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-31 means
The payer can't match the patient to an active member on its file. Reported under the PR group, but the first move is to verify the patient's coverage — the usual cause is a fixable data error or a wrong payer, not a true patient balance.
Why PR-31 happens
- A wrong or transposed member/subscriber ID
- The claim went to the wrong payer or wrong plan
- The patient's name or date of birth doesn't match the enrollment record
- Coverage wasn't active on the date of service, or the patient isn't enrolled
What to do when you get PR-31
- 1Re-verify eligibility from the card/portal — member ID, name, DOB, and plan
- 2Correct any mismatched identifier and resubmit a corrected claim
- 3If the patient isn't this payer's member, refile to the correct payer
- 4Only if no coverage applies does the balance become the patient's responsibility
Got this denial right now?
Ask D3 whether to appeal or correct PR-31
PR-31 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-31?
Despite the PR group code, PR-31 usually resolves as a corrected claim or a refile — fix the member identifiers from verified eligibility, or send the claim to the payer that actually covers the patient. Bill the patient only after confirming there was genuinely no coverage on the date of service. Appeal with proof only if the patient WAS this payer's active insured and the data was correct.
Timing & deadlines
Correct or refile within the payer's timely-filing limit (Medicare 12 months from date of service; commercial ~90-180 days). Act quickly, since a wrong-payer detour consumes the filing window.
Example
A claim returns PR-31 because the member ID was entered from an expired card. Pulling the patient's current card, correcting the ID, and resubmitting clears it — no patient bill needed.
Prevent PR-31 going forward
- Scan current insurance cards and verify eligibility before the date of service
- Validate member ID, name, and DOB at registration
- Re-verify coverage at each visit and after any plan change
- Confirm the correct payer/plan before billing the patient
Code families most affected
- All claim types (identity/eligibility is service-agnostic)
- Patients with recent plan changes or multiple coverages
- Claims routed to the wrong payer or plan
Related codes
Payer notes
CARC 31 appears under both CO and PR depending on the payer. The PR variant suggests possible patient liability, but verify coverage first — the typical cause is a correctable ID error or a wrong payer, not true non-coverage.
Not sure how to work PR-31?
Ask D3 whether PR-31 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.