Service before coverage began
The date of service is before the patient's coverage with this payer started.
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
- New plan: the effective date is after the visit.
- Wrong date of service on the claim.
- Coverage was retroactively started and the payer's file has not caught up.
The fix
Check the date of service and the coverage start date on the eligibility response. If the date is wrong, send a corrected claim. If the patient had a different plan on that date, bill it. Otherwise the balance is the patient's.
Appeal or corrected claim?
Corrected claim for a date error; otherwise bill the patient or the plan that was active.
Deadline to watch
Timely filing limit of the plan that was active on the date of service.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
PR-26 in short
What does PR-26 mean?
The date of service is before the patient's coverage with this payer started. The official X12 text reads: "Expenses incurred prior to coverage."
What usually causes a PR-26 denial?
New plan: the effective date is after the visit. Wrong date of service on the claim. Coverage was retroactively started and the payer's file has not caught up.
How do I fix PR-26?
Check the date of service and the coverage start date on the eligibility response. If the date is wrong, send a corrected claim. If the patient had a different plan on that date, bill it. Otherwise the balance is the patient's.
Should I appeal PR-26 or send a corrected claim?
Patient responsibility. Corrected claim for a date error; otherwise bill the patient or the plan that was active.
What deadline applies to PR-26?
Timely filing limit of the plan that was active on the date of service.