PR-22 Denial Code: Other Insurance Suspected, Patient Balance

What is the PR-22 denial code? PR-22 is a Claim Adjustment Reason Code (CARC) meaning "This care may be covered by another payer per coordination of benefits," reported with the Patient Responsibility (PR) group code, so the payer is assigning the unpaid amount to the patient until the payment order is resolved.

Undeny's Take

The PR label tempts staff to send a statement, but the money usually sits with another plan, not with the patient. What the payer really wants is an answer to "who pays first," and it has pushed that question onto the member. Get the answer yourself. For Medicare patients this is not optional: a Medicare contractor's guidance says providers must determine whether Medicare is primary or secondary, and that failing to keep a system for identifying other payers is viewed as a violation of the provider agreement. Ask about other coverage at intake and write the answer down, and fewer PR-22 lines will appear. When one does, a corrected payment order and a rebill are usually the faster path to payment than a patient statement.

What PR-22 Means and Why the Group Code Matters

X12 defines reason code 22 as "This care may be covered by another payer per coordination of benefits." The Medicare Claims Processing Manual (Pub. 100-04, Chapter 22) defines group PR as an adjustment that "may be billed to the patient or insured," while CO is generally a provider write-off. CO-22 is the more familiar version; the PR group signals that the payer expects the member to clear up the other-coverage question.

The fix also changes once another plan has paid. A secondary claim then reports the primary's adjustments, which is where OA-23 shows up on the secondary's remittance.

Why a Payer Suspects Another Primary Plan

• The patient has coverage that pays before this plan. For Medicare, WPS (a Medicare contractor) lists employer group health plans with 20 or more employees for patients 65 and older, large group plans with 100 or more employees for disabled patients under 65, and the first 30 months of coverage for end-stage renal disease.
• The service may relate to an injury or illness another insurer covers. WPS names no-fault, liability and workers' compensation insurance as non-group payers that pay before Medicare when the diagnosis ties the claim to that event.
• The payer's other-coverage record is stale. WPS notes that the Benefits Coordination & Recovery Center (BCRC), not the claims contractor, maintains Medicare's records of other primary insurance.
• The secondary was billed before the primary. If the primary has not adjudicated the claim yet, the secondary has nothing to coordinate against.

How to Fix a PR-22 and Rebill

1. Ask the patient about every active plan, including a spouse's employer plan and any accident or workers' compensation claim. For Medicare patients, WPS recommends the MSP questionnaire in the Medicare Secondary Payer Manual (Pub. 100-05, Chapter 3, section 20.2.1).
2. Check the eligibility response. WPS says its portal shows Medicare Secondary Payer information along with entitlement and Medicare Advantage enrollment.
3. If another plan is primary, bill it first. Then send the secondary claim with the primary's payment and adjustment information. For Medicare secondary claims, CMS says the provider must report the primary payer's 835 adjustments on the 837 "unchanged."
4. If the patient says the payer's record is wrong, have it corrected before rebilling. For Medicare, WPS directs providers to contact the BCRC to report changes and verify primary or secondary status, and notes the BCRC "will not release insurer information," so the details must come from the patient.
5. If the payer still denies after the order is confirmed and the primary's remittance is attached, appeal with that evidence. The appeal generator can draft it.
6. Bill the patient only if the patient refuses to give the other-coverage information the plan needs, and follow your financial policy when you do.

PR-22 Compared With CO-22, OA-23, CO-109 and PR-31

CO-22 is the same coordination reason with the provider-liability group. OA-23 reports the impact of a prior payer's adjudication on a secondary claim. CO-109 means this payer does not cover the claim at all and it belongs with another payer or contractor. PR-31 means the payer cannot identify the patient as its insured, and CO-27 means the service fell after coverage ended.

Frequently Asked Questions

Can I bill the patient for a PR-22 denial?

The PR group allows it, but it is usually premature. The payer is waiting on the other-coverage answer, and once the primary plan is billed and the order is confirmed, the claim can be paid by insurance. Reserve patient billing for cases where the patient will not supply the coverage information.

What is the difference between PR-22 and CO-22?

Both say another payer may be primary under coordination of benefits. CO marks the amount as a provider adjustment, while PR assigns it to the patient, which suggests the plan expects the member to confirm or update other coverage. The practical fix for both is the same: establish the correct payment order and rebill.

Who updates Medicare's record of other insurance?

The Benefits Coordination & Recovery Center maintains Medicare's records of primary coverage. A Medicare contractor notes that providers may contact it to verify Medicare's primary or secondary status and report coverage changes, but it will not release the other insurer's details. You need those from the patient.

Do I need to send Medicare a claim if the primary paid in full?

Sometimes. A Medicare contractor lists inpatient claims, outpatient claims with an unmet Medicare deductible, and claims the primary partly paid or fully denied as situations that still need a secondary claim. Medicare uses the primary's payment information to credit the deductible and track benefits.

Is anything changing for Medicare Part A secondary claims?

Yes. CMS Transmittal 13932 (Change Request 14553) tells Part A contractors that, for dates of service from January 1, 2027, Medicare Secondary Payer claims carrying CARC 22 from the primary payer will be rejected. Institutional providers, including outpatient therapy settings that bill Part A contractors, should resolve the primary's coordination denial before sending the claim to Medicare.

Informational only, not legal, medical, or billing advice. Always verify against your current payer contract and policy.

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