Lifetime benefit maximum reached
The patient has used up a lifetime limit for this benefit under the plan.
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
- Benefits with lifetime caps (some dental, infertility, hearing or therapy benefits).
- Medicare lifetime reserve days or psychiatric hospital limits.
The fix
Confirm the limit with the payer. The balance becomes patient responsibility, so tell the patient before further services and offer a payment plan or alternative coverage check.
Appeal or corrected claim?
Nothing to appeal unless the payer counted services wrongly; then ask for an accumulator review.
Deadline to watch
None from the payer.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
PR-35 in short
What does PR-35 mean?
The patient has used up a lifetime limit for this benefit under the plan. The official X12 text reads: "Lifetime benefit maximum has been reached."
What usually causes a PR-35 denial?
Benefits with lifetime caps (some dental, infertility, hearing or therapy benefits). Medicare lifetime reserve days or psychiatric hospital limits.
How do I fix PR-35?
Confirm the limit with the payer. The balance becomes patient responsibility, so tell the patient before further services and offer a payment plan or alternative coverage check.
Should I appeal PR-35 or send a corrected claim?
Patient responsibility. Nothing to appeal unless the payer counted services wrongly; then ask for an accumulator review.
What deadline applies to PR-35?
None from the payer.