Medical claim denial codes are found on documents like your Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). These codes serve as the official notice from the insurance payer to the healthcare provider, explaining why a claim was not paid or was paid differently than expected. The prefix “PR” preceding a denial code stands for “Patient Responsibility,” signifying that the financial burden for the service has been transferred to the individual rather than the insurer.
Defining the PR 27 Denial Code
The PR 27 denial code is an explicit message from your insurance company stating, “Expenses incurred after coverage terminated.” This means the entire cost of the healthcare service falls to the patient. The insurance plan is asserting that on the date the medical service was rendered, the patient was no longer an active enrollee in the policy.
The “PR” designation is important because it gives the healthcare provider the legal right to bill the patient directly for the full amount of the service. This is distinct from a “CO” (Contractual Obligation) code, which means the provider cannot bill the patient due to their contract with the payer. With PR 27, the payer confirms that no contract terms apply because the patient’s coverage was inactive on the date of service.
The insurance company is communicating that their obligation to pay ended before the service took place. This denial is purely a statement about the patient’s enrollment status, not related to medical necessity or a non-covered service. Receiving this code requires immediate action to either prove continuous coverage or arrange for payment of the outstanding balance.
Root Causes for Receiving PR 27
One of the most frequent reasons a PR 27 code is issued involves simple administrative errors. The provider’s billing team may have outdated insurance information on file, especially if a patient changed plans but did not communicate the new details before the visit. Billing errors, such as a typo in the patient’s member ID or an incorrect effective date, can also cause the claim to reject as if the policy were terminated.
A common cause is a lapse in coverage due to the non-payment of premiums. If an individual fails to pay their monthly premium by the due date, the insurance company will terminate the policy, and any services received after that termination date will be denied.
A change in employment status is a frequent trigger for this denial, as coverage often ends on the last day of work. If a person transitions between jobs, there may be a gap between the old employer’s plan and the new one, or a delay in COBRA enrollment, making them technically uninsured for a brief period. Dependents aging out of a parent’s plan is another specific scenario that results in this denial, as coverage typically terminates at age 26.
Finally, delays in the submission of the claim by the provider can inadvertently lead to this denial. If the service was rendered while the patient was covered, but the claim was not submitted until after the coverage termination date, the payer may still issue the PR 27 code. This timing issue can occur if a claim is rejected multiple times for minor errors, delaying its final submission past the patient’s coverage end date.
Action Steps for Appealing the Denial
The first step upon receiving a PR 27 denial is to contact the insurance payer directly, not the healthcare provider. You must verify the exact date the insurer claims the coverage was terminated and the precise reason for that termination. This establishes the official date of non-coverage, which is central to any subsequent appeal.
If you have documentation showing that you were indeed covered on the date of service, you must prepare to appeal the denial. Gather supporting evidence, such as confirmation of enrollment, proof of premium payments for the period in question, or a policy document showing the correct coverage dates. This documentation is necessary to prove the insurer’s termination date is incorrect or that the service occurred before coverage lapsed.
The process involves submitting a formal appeal to the insurance company, requesting an internal review of the claim. If the termination was due to a provider’s administrative error, such as an incorrect date of service, you should also communicate with the provider’s billing office. The provider may need to correct and resubmit the claim with the accurate information to resolve the issue.
If the denial is upheld because the service truly occurred after coverage ended, the focus shifts to resolving the financial obligation with the provider. At this stage, you can discuss payment plans, financial assistance programs, or a potential reduction in the bill, as the provider is no longer constrained by the insurance company’s contracted rates.