Can I bill the patient for a PR-27?

Usually yes. PR means patient responsibility, and Medicare describes PR as the amount the provider can collect from the patient. Check three things first: that coverage really had ended on the date of service, that no replacement plan exists, and that your contract and your state's rules do not restrict billing in this situation. Medicaid programs in particular often bar billing the member.

What is the difference between PR-27 and CO-27?

The reason is the same: the service happened after coverage ended. The letters decide who pays. PR puts the balance on the patient. CO puts it on the practice as a contractual write-off, which often points at a contract term about verifying eligibility. Never move a CO amount onto a patient statement.

The patient says they were covered. What now?

Check eligibility for the date of service, not for today. If the payer's own system shows the patient active on that date, that is your appeal, and you attach the eligibility response. If it shows a termination date before the visit, ask the patient what replaced the plan and bill that payer instead.

The payer already paid and now wants the money back. Is that allowed?

It happens when a member is terminated retroactively, after claims were already paid. The payer recovers the money on a later remittance. How far back a payer may go is set by state law and by your contract, so check both rather than assuming the takeback is final.

RemitBench/Denial codes/PR-27

PR-27 denial code

The payer says coverage had already ended on the date of service. Find where the coverage went before you bill anyone.

What it means: The plan had already ended on the date of service, so this payer will not pay for it.
Who owes the money: Patient balance PR puts the amount on the patient, and Medicare describes PR as what the provider can collect from them. Check for a replacement plan before you act on that, and check whether your contract or your state limits it.
Is appealing worth it: Only if you can show coverage was live on the date of service. Otherwise this is not an appeal at all. It is a rebill to whoever the patient's plan actually was.

Do not send the statement first. Most of these patients had coverage on that date, just not the coverage in your chart. Find the replacement plan and bill that payer.

Three cases where you cannot bill the patient: Medicaid, where most state programs bar billing the member. A contract with a hold harmless clause, which often survives the plan ending. A patient flagged QMB (remark code N781), where federal law bars the bill even if the patient offers to pay.

Why the payer sent it

The reason is almost always ordinary. Coverage moved and nobody at the front desk knew.

The patient changed jobs, and the old plan ended on their last day or at the end of that month.
They moved to a different plan at open enrollment and the card in your chart is last year's.
They turned 65 and moved to Medicare, or to a Medicare Advantage plan.
COBRA ran out, or the premium was not paid.
A marketplace plan lapsed for unpaid premiums.
A dependent aged off the parent's plan.
The payer's eligibility file lagged, and the termination was applied later than it happened.

Remark codes you will see with it

The remark code narrows it down, and sometimes it decides who pays. These are the ones the industry standard allows with reason code 27.

Remark code	What it adds
N30	The patient was not eligible for this service.
N619	Coverage ended because the premium was not paid. This is the marketplace case below.
N52	The patient was not in your managed care plan on that date. Often a network problem rather than a coverage one.
N650	The policy was not in force for this date of loss. Turns up on accident and liability claims.
N622	Not covered based on the date of the injury or accident.
MA47	The provider opted out of Medicare, and the patient is responsible for payment.
N905	The provider opted out of Medicare, and the patient is not responsible for payment.

Remark code

What it adds

N30

The patient was not eligible for this service.

N619

Coverage ended because the premium was not paid. This is the marketplace case below.

N52

The patient was not in your managed care plan on that date. Often a network problem rather than a coverage one.

N650

The policy was not in force for this date of loss. Turns up on accident and liability claims.

N622

Not covered based on the date of the injury or accident.

MA47

The provider opted out of Medicare, and the patient is responsible for payment.

N905

The provider opted out of Medicare, and the patient is not responsible for payment.

Look at those last two. Same situation, opposite answer on who pays. That is the clearest argument on this whole site for reading the remark code instead of stopping at the reason code.

The retroactive termination trap

This is the expensive version. A payer can end a member's coverage back to a date in the past, after it has already paid your claims. The money then comes back off a later remittance as a takeback, sometimes months after you posted it.

When that happens, do not just post the recovery. How far back a payer may reach is set by state law and by your contract. Check both before you accept it.

The marketplace grace period

Marketplace plans with a premium subsidy work differently, and the rule is worth knowing because it explains a claim that was fine one month and denied the next.

A subsidized member who stops paying gets a three month grace period. The plan must pay claims from the first month. It is allowed to hold claims from the second and third months, and it has to tell providers that those claims may end up denied. If the member never catches up, coverage ends back at the end of that first month, and everything after it becomes the patient's problem and yours.

If a payer tells you a patient is "in the grace period", treat those visits as at risk. Collect at the time of service where you can, and do not schedule a large case on that coverage without asking.

Read the letters in front of the 27

This code carries the sharpest split of any on this site. Same number, opposite bill.

PR-27: Patient responsibility. You may bill the patient, subject to your contract and your state's rules.
CO-27: Contractual obligation. The payer is putting the amount on the practice. This often points at a contract term about checking eligibility. Do not move it to a statement.
PI-27: Payer initiated. Also not the patient's. Medicare cannot use PI, but commercial and dental plans do.

What to do next

Check eligibility for the date of service

Not for today. Today's answer tells you nothing about a visit six weeks ago. Use the payer's own portal or your clearinghouse and set the date to the date on the claim.
If it shows the patient active on that date: you have an appeal, and you have the evidence. Save the eligibility response as a file and send it with the appeal. Stop here. If it shows a termination date before the visit: the denial is right. Go to step 2.
Find the coverage that replaced it

There usually is some. This is the step that turns a write-off back into a payment, and it is the one most often skipped.
Call the patient. Ask what changed and ask them to read you the new card. This one phone call recovers more of these claims than anything else on the page. If Medicare denied it: look for a Medicare Advantage plan. Medicare sends a different code for that, reason code 24, but eligibility churn and plan changes travel together. Check for both. If the patient is unreachable: run an eligibility search across payers if your clearinghouse offers one. Many find the active plan from the member's details alone.
Bill the new payer fast

The new payer's filing deadline started on the date of service, not on the day you found out. You have already spent some of it waiting for the first denial. Work these ahead of older, quieter claims.
If the deadline has already passed: some payers accept proof that you were pursuing another carrier in good faith. Send the first payer's remittance as evidence. It does not always work, and it is worth trying before you write off the whole amount.
Only now decide about the patient

If there is genuinely no other coverage, PR-27 does put the balance on the patient. Before the statement goes out, confirm three things: the line is PR and not CO, your contract with that payer does not restrict it, and the patient is not covered by a program that bars member billing.
When you do bill: tell the patient why in plain words. "Your plan ended on the 31st and the visit was on the 4th" gets paid. A statement with a code on it gets a phone call.

What PR-27 gets confused with

Several codes all feel like "the insurance is wrong". They need different work, so the difference is worth ten seconds.

Code	How it differs from 27
26	The mirror image. The visit was before coverage started, not after it ended. Often a start date one day off, so it is worth checking.
31	The payer cannot match the patient to a member at all. That is usually a typo in the ID, the name, or the birth date, not a coverage change.
32	The patient is not an eligible dependent. Coverage exists, but not for this person.
33	The plan has no dependent coverage on it. The subscriber is covered and the family member is not.
24	The patient is in a managed care or Medicare Advantage plan. Not a termination, a routing problem. Send it to that plan.
109	Wrong payer entirely. The plan is fine, the claim went to the wrong company.
119	The benefit maximum was used up. Coverage is active. This is the one dental offices mistake for a termination most often.
29	Timely filing. This is what a PR-27 turns into if you spend three months chasing the wrong payer.

When not to appeal

The payer's own eligibility system shows the coverage ended before the visit. There is nothing to argue. Rebill or bill the patient.
You have not checked eligibility for the date of service yet. Do that first. It decides which path you are on.
The patient has told you about a new plan. Bill that plan. An appeal to a payer with no member is a wasted month.
The only thing you have is the patient's word. Get the new card or an eligibility response before you spend the time.

Appeal when the payer's own record contradicts its own denial. That is a strong appeal and it usually wins. Every other version of this is a rebill wearing an appeal's clothes.

Does PR-27 show up in dental?

More than the other two codes on this site, and for a reason that is specific to dental work.

Dental benefits are usually a separate policy from medical, often with a different carrier and a different end date. A patient can keep their medical plan and lose their dental plan on the same job change. Offices check the medical card, see it is fine, and miss it.

The case that costs real money

Dental treatment is planned in advance and delivered in stages, so a case can start inside coverage and finish outside it. A crown prepped in one month and seated two months later is the classic example. If the plan ended in between, which date the payer uses decides whether it pays at all.

Carriers do not all use the same date for this, and the answer is in that plan's processing policy rather than in any code list. So ask before you seat, not after. For a large case spanning a coverage change, get the answer in writing.

Two things that look like PR-27 and are not

The annual maximum ran out. That is reason code 119, and coverage is still active. Completely different conversation with the patient.
A waiting period. Coverage exists but this benefit has not started yet. Also not a termination.

One practical note. Many dental payers still send a paper or PDF EOB that prints a sentence instead of a code. You get "patient not eligible on date of service" with no CARC at all, which is the same message with nothing to look up.

Related codes

Back to all denial codes

RemitBench reads dental EOB PDFs and turns them into posting-ready lines, in your browser, with no upload. It does not read medical remittances today.

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