Benefit maximum for this period reached
The patient has used all of this benefit for the year or the period (for example a visit limit for therapy or chiropractic care, or a dollar cap).
PR = Patient Responsibility. The patient owes this amount (deductible, coinsurance, copay or a non-covered service the patient agreed to pay for). The same reason code can appear with a different group code; the group decides who may be billed.
Usual causes
- Therapy, chiropractic, acupuncture or mental health visit limits.
- Annual dollar caps on some benefits.
- Frequency limits for exams, imaging or supplies.
The fix
Confirm the limit and the count with the payer; counts can be wrong when another provider's claims were included. If the limit is right, the balance is patient responsibility (tell patients when they are near the limit). For Medicare therapy, the KX modifier attests that services above the threshold are necessary.
Appeal or corrected claim?
Nothing to appeal when the count is correct. Ask for an accumulator review when it is not. Medical necessity appeal when the plan allows exceptions.
Deadline to watch
Appeal window per payer.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
PR-119 in short
What does PR-119 mean?
The patient has used all of this benefit for the year or the period (for example a visit limit for therapy or chiropractic care, or a dollar cap). The official X12 text reads: "Benefit maximum for this time period or occurrence has been reached."
What usually causes a PR-119 denial?
Therapy, chiropractic, acupuncture or mental health visit limits. Annual dollar caps on some benefits. Frequency limits for exams, imaging or supplies.
How do I fix PR-119?
Confirm the limit and the count with the payer; counts can be wrong when another provider's claims were included. If the limit is right, the balance is patient responsibility (tell patients when they are near the limit). For Medicare therapy, the KX modifier attests that services above the threshold are necessary.
Should I appeal PR-119 or send a corrected claim?
Patient responsibility. Nothing to appeal when the count is correct. Ask for an accumulator review when it is not. Medical necessity appeal when the plan allows exceptions.
What deadline applies to PR-119?
Appeal window per payer.