PR-155 Denials Explained: How to Identify, Appeal, and Prevent Them

Denial codes are a common and often frustrating challenge for healthcare revenue cycle teams, with PR-155 being one that frequently impacts reimbursement. This denial occurs when a patient refuses a recommended service or procedure, creating a unique set of issues for providers and billing teams.

Understanding PR-155 denials is essential to minimize revenue leakage and operational disruptions. In this guide, we’ll explain what this denial means, how it compares to similar codes, common causes, and actionable strategies to appeal and prevent them.

What Is a PR-155 Denial?

The PR-155 denial code is defined as "Patient refused the service/procedure." The prefix “PR” stands for “Patient Responsibility,” which indicates that the financial obligation lies with the patient. This denial occurs when the patient declines to proceed with a recommended service or procedure, leaving no opportunity for reimbursement by the payer.

In these cases, providers must engage in proactive communication with patients to understand and address their concerns prior to rendering services, as the refusal directly impacts revenue.

Comparison: PR-155 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-155	Patient Responsibility	Patient refused the service/procedure.	Patient
PR-56	Patient Responsibility	Procedure/service deemed not medically necessary by the patient.	Patient
CO-45	Contractual Obligation	Charge exceeds the contractually agreed amount.	Provider

The key difference between PR-155 and similar codes lies in the reason for the denial. While PR-155 relates to patient refusal, PR-56 involves disputes over medical necessity, and CO-45 pertains to contractual agreements between the provider and payer.

Common Causes of PR-155 Denials

1. Lack of Patient Education: Patients may refuse services due to a lack of understanding about the necessity or benefits of the recommended procedure.
2. High Out-of-Pocket Costs: Patients may decline services if they perceive the financial burden to be too high, even with insurance coverage.
3. Fear or Mistrust: Concerns about the procedure's risks or distrust in the healthcare provider may lead patients to refuse treatment.
4. Inadequate Pre-Service Communication: Providers may fail to discuss service details, costs, and benefits clearly with patients, resulting in refusal.
5. Delayed Scheduling: Patients may reconsider or refuse services if there is a significant delay between the recommendation and scheduling.

Impact on Revenue Cycle Teams

PR-155 denials can have a far-reaching impact on both financial and operational aspects of the revenue cycle.

Financial Impact:

• Lost Revenue: Claims cannot be billed to payers, resulting in lost revenue.
• Increased AR Days: Time spent on patient follow-ups delays payments.
• Higher Write-Offs: If patients ultimately refuse to pay, providers may face increased write-offs.
• Resource Allocation Costs: Staff time and resources are needed to manage denials and appeals.

Operational Impact:

• Staff Disruptions: Time spent resolving these denials reduces efficiency in other RCM functions.
• Coordination Challenges: Resolving PR-155 denials often requires collaboration between clinical, billing, and administrative teams.
• Documentation Gaps: Inadequate clinical and administrative documentation can complicate the appeal process.
• Denial Tracking: Repeated PR-155 denials may signal systemic issues requiring ongoing monitoring and intervention.

To overcome these challenges, healthcare organizations can leverage CombineHealth.ai’s innovative solutions. With Adam (AI Denial Manager), RCM teams can efficiently identify and manage PR-155 denials, reducing financial risks and operational inefficiencies.

Steps To Appeal a PR-155 Denial

When a PR-155 denial occurs, following these steps can improve the chances of a successful appeal:

Step 1: Review the Denial Notice
Carefully read the Explanation of Benefits (EOB) or Remittance Advice (RA) to confirm the denial reason and ensure it aligns with PR-155.

Step 2: Gather Documentation
Collect all relevant documents, including clinical notes, patient consent forms, and communication records, to support the appeal.

Step 3: Verify Eligibility
Confirm that the patient’s insurance coverage and eligibility were verified prior to the service being recommended.

Step 4: Prepare Appeal Letter
Draft a concise appeal letter outlining the denial details, supporting evidence, and justification for overturning the denial. Ensure the letter adheres to payer-specific guidelines.

Step 5: Submit Within Deadline
Appeals must be submitted within the timelines set by the payer. Missing deadlines can result in automatic rejections.

Step 6: Track and Follow Up
Monitor the status of the appeal and follow up with the payer to ensure timely resolution.

How To Prevent PR-155 Denials

Preventing PR-155 denials requires a proactive approach across multiple stages of the revenue cycle.

Front-End Prevention

• Patient Education: Clearly explain the medical necessity, benefits, and risks of the recommended service.
• Transparent Cost Discussions: Provide upfront cost estimates and discuss payment options to address financial concerns.

Billing Best Practices

• Accurate Documentation: Ensure clinical notes and consent forms are complete and accurately reflect the patient’s decision.
• Timely Eligibility Verification: Confirm insurance coverage and patient responsibility before scheduling procedures.

Technology Solutions

• Automated Communication Tools: Use technology to send reminders about service benefits and address patient concerns in real-time.
• AI-Powered Denial Management: CombineHealth.ai’s intelligent platform identifies potential denial risks and ensures proper documentation. Rachel (AI Appeals Manager) streamlines the appeals process, reducing manual effort and improving success rates.

FAQs

Q1: What does PR-155 mean in medical billing?
PR-155 indicates that the patient refused a recommended service or procedure, making them financially responsible.

Q2: Can PR-155 denials be appealed?
Yes, PR-155 denials can be appealed, provided there is sufficient documentation and justification.

Q3: How long do I have to appeal?
The appeal timeline varies by payer but is typically 30-90 days from the date of denial. Always verify with the specific payer’s guidelines.

Q4: How can I prevent these denials?
Proactively educate patients, provide cost transparency, and use tools like CombineHealth.ai’s denial management solutions. See our complete guide on denial prevention.
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