PR-227 Denial Code: The Patient Never Answered the Payer

What is the PR-227 denial code? PR-227 is a Claim Adjustment Reason Code (CARC) meaning "Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete," reported with the Patient Responsibility (PR) group, and X12 requires at least one non-Alert remark code with it to identify what is missing.

Undeny's Take

PR-227 is a patient-outreach task with a deadline, not a coding problem. A patient may not connect a form from their insurer with your bill, so a statement that says "you owe the full visit" can land as a surprise and sit unpaid. A short call that names the form and gives the member-services number is the better first move, because remark code N179, when it appears, says the charges "will be reconsidered upon receipt of that information." Two habits help: read the remark code before anything else, because it names the missing item, and log the date the patient says they responded, so you can prove it if the payer stalls.

What PR-227 Means and Which Remark Codes Explain It

X12's full description of reason 227 is "Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)" The Medicare Claims Processing Manual (Pub. 100-04, Chapter 22) defines group PR as an amount that "may be billed to the patient or insured."

Because 227 alone does not say what was requested, the remark code carries the detail. Remark codes on the official X12 list that describe a member-side request include:

• N179: "Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information."
• N686: "Missing/incomplete/Invalid questionnaire needed to complete payment determination."
• N375: "Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility."

Which one appears depends on the payer and the request.

Why Payers Assign PR-227

• The member questionnaire was never returned. The remark codes above show the kinds of requests involved: information requested from the member, questionnaires needed for a payment determination, and questionnaires about dependent eligibility.
• The answer came back incomplete. The 227 description covers information that was "insufficient/incomplete," not only information never sent.
• The request reached the wrong place. A patient who moved or changed email may never have seen it, which is worth asking about before you assume refusal.

How to Resolve a PR-227

1. Read the remark code on the line to learn what the payer asked for.
2. Call the payer or check its portal to confirm the request, who it was sent to, and any response deadline. Aetna, for example, tells providers that the remarks on a pended claim's EOB say "what we need, how to send it and the submission deadline."
3. Contact the patient, explain that the plan is waiting on them, and give them the member-services number or form.
4. Once the patient confirms they responded, ask the payer to reprocess the claim and note the date and reference number.
5. If the patient had already responded before the denial, appeal with their confirmation. The appeal generator can draft the letter.
6. If the patient will not respond, bill them under your financial policy with the remittance attached, since the PR group assigns the amount to them.

PR-227 Compared With CARC 226, CO-16, CO-252 and CO-22

CARC 226 is the provider-side twin: the payer asked the billing or rendering provider for information and did not get it. CO-16 means the claim itself lacks information or has a billing error. CO-252 means an attachment or other documentation is needed to adjudicate the service. CO-22 is the coordination-of-benefits code you may see when the missing answer was about other insurance, and PR-31 means the patient cannot be identified as an insured.

Frequently Asked Questions

Who is supposed to send the missing information on a PR-227?

The patient, insured or responsible party, because the payer's request went to them rather than to the provider. You can help by explaining what the plan needs and how to reach member services, then asking the patient to tell you when they have responded.

Can I bill the patient for a PR-227 denial?

The PR group allows it, but billing first can turn a payable claim into a patient balance. If the patient answers and the plan reprocesses, insurance pays its share and the patient owes only normal cost sharing. Bill the patient if they decline to respond or the plan confirms the answer will not change the outcome.

What is the difference between PR-227 and CO-226?

Both say requested information was not provided. CARC 227 covers requests made to the patient, insured or responsible party, while CARC 226 covers requests made to the billing or rendering provider. Check the group code on each line, since it shows whom the payer holds responsible.

Which remark code tells me what the payer wants?

X12 requires at least one remark code that is not an Alert with CARC 227. Codes such as N179, N686 and N375 describe information requested from the member or a missing questionnaire. If the remark is unclear, ask the payer what was requested and when.

Does a PR-227 from a primary payer affect Medicare secondary billing?

It can. CMS Transmittal 13932 (Change Request 14553) tells Part A contractors that, for dates of service from January 1, 2027, Medicare Secondary Payer claims showing CARC 227 with a primary payment amount will be rejected. Resolve the primary plan's request first.

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

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