Denial Code PR 275 - Resolve Patient Responsibility Issues

Why Claims Get Code 275

• The primary insurance plan included a patient responsibility portion that was not paid by the secondary payer.
• Coordination of Benefits (COB) was not properly followed, leaving the patient's share unpaid.
• The secondary payer does not cover amounts considered patient responsibility by the primary payer.
• Patient's prior insurance deductible or coinsurance was not met.
• Incorrect submission of claims to the secondary payer without indicating prior payer's patient responsibility.

How to Fix & Resubmit

1. Verify the Coordination of Benefits information to ensure the correct order of payers is established.
2. Confirm the patient's responsibility amounts with the primary payer's Explanation of Benefits (EOB).
3. Ensure that the claim was submitted to the secondary payer with the correct information regarding the prior payer's patient responsibility.
4. Contact the secondary payer to confirm if they cover any part of the prior payer's patient responsibility.
5. Bill the patient for the deductible, coinsurance, or co-payment not covered by the secondary payer.

Preventing Future 275 Denials

• Ensure accurate and complete Coordination of Benefits information is on file for each patient.
• Train staff to verify and document patient responsibility from the primary payer's EOB before billing the secondary payer.
• Implement a checklist for claims submission to secondary payers to include prior payer's patient responsibility details.
• Regularly review payer policies regarding coverage of prior payer's patient responsibilities.