Pre-existing condition
The payer says the condition existed before the coverage began and the plan excludes it.
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
- Plans not subject to Affordable Care Act rules (some short-term, grandfathered or supplemental plans) still exclude pre-existing conditions.
- Payer assumed the condition was pre-existing from the diagnosis alone.
The fix
Ask the payer which plan rule applies; most health plans may not exclude pre-existing conditions. If the exclusion is valid, the patient owes the balance. If the payer assumed, appeal with records showing when the condition was first diagnosed.
Appeal or corrected claim?
Appeal with the first-diagnosis date; otherwise bill the patient.
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-51 in short
What does PR-51 mean?
The payer says the condition existed before the coverage began and the plan excludes it. The official X12 text reads: "These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."
What usually causes a PR-51 denial?
Plans not subject to Affordable Care Act rules (some short-term, grandfathered or supplemental plans) still exclude pre-existing conditions. Payer assumed the condition was pre-existing from the diagnosis alone.
How do I fix PR-51?
Ask the payer which plan rule applies; most health plans may not exclude pre-existing conditions. If the exclusion is valid, the patient owes the balance. If the payer assumed, appeal with records showing when the condition was first diagnosed.
Should I appeal PR-51 or send a corrected claim?
Appeal. Appeal with the first-diagnosis date; otherwise bill the patient.
What deadline applies to PR-51?
Appeal window per payer.