PR-247 Denials Explained: How to Identify, Appeal, and Prevent Them

A PR-247 denial can disrupt healthcare revenue cycle operations, creating financial setbacks and operational inefficiencies. This denial code pertains to patient deductibles for professional services rendered in institutional settings, billed on institutional claims. For revenue cycle teams, understanding PR-247 denials is vital to managing claims effectively and reducing revenue leakage.

In this article, we’ll explore the specifics of PR-247 denials, their causes, financial implications, and actionable strategies for appealing and preventing them.

What Is a PR-247 Denial?

PR-247 is a denial code indicating that a patient’s deductible applies to professional services provided in an institutional setting and billed on an institutional UB-04 claim. The prefix “PR” stands for Patient Responsibility, signifying that the patient is financially accountable for the amount indicated.

This denial occurs when a payer determines that the claim should be applied to the patient’s deductible rather than reimbursed to the provider. Unlike contractual obligation denials (CO) or other adjustment-related denials (OA), PR-247 specifically emphasizes the patient’s financial responsibility.

Comparison: PR-247 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-247	Patient Responsibility	Deductible for professional service rendered in an institutional setting and billed on an institutional claim.	Patient
CO-45	Contractual Obligation	Charges exceed the fee schedule or maximum allowable amount.	Provider
OA-18	Other Adjustment	Duplicate claim or service already processed.	Provider/Payer

PR-247 differs from CO-45 and OA-18 in that it pertains solely to patient deductibles applied to specific claim settings, while CO and OA codes involve contractual agreements or payer adjustments.

Common Causes of PR-247 Denials

1. Incorrect Claim Submission: Professional services billed on institutional UB-04 claims instead of professional CMS-1500 forms.
2. Eligibility Verification Errors: Failure to confirm the patient’s deductible status and coverage details prior to claim submission.
3. Clinical Documentation Issues: Insufficient documentation supporting the professional service rendered in the institutional setting.
4. Policy Misalignment: Lack of clarity on payer-specific policies regarding deductibles for institutional claims.
5. Coding Errors: Incorrect coding of services, leading to mismatches against payer requirements.

Impact on Revenue Cycle Teams

PR-247 denials pose substantial challenges to healthcare organizations, necessitating robust denial management processes.

Financial Impact:
- Revenue loss due to denied claims requiring rework.
- Extended accounts receivable cycles, delaying cash flow.
- Risk of write-offs if appeals fail or deadlines are missed.
- Higher operational costs for denial resolution.

Operational Impact:
- Increased workload for billing and coding teams.
- Need for specialized knowledge of payer-specific policies.
- Collaboration challenges between clinical and administrative teams.
- Greater focus on tracking denial trends and optimizing workflows.

CombineHealth.ai’s AI-powered solutions, including Adam (AI Denial Manager), help healthcare organizations streamline denial resolution and mitigate these impacts effectively. Adam identifies denial patterns, automates tracking, and provides actionable insights to minimize revenue leakage.

Steps To Appeal a PR-247 Denial

Step 1: Review the Denial Notice
Carefully analyze the explanation of benefits (EOB) or remittance advice (RA) to confirm the denial reason and identify any discrepancies.

Step 2: Gather Documentation
Collect all relevant documents, including patient eligibility records, clinical notes, and billing data, to substantiate the claim.

Step 3: Verify Eligibility
Confirm that the patient’s insurance coverage and deductible details align with the services provided and billed.

Step 4: Prepare Appeal Letter
Draft a concise appeal letter addressing the denial reason, supported by proper documentation and referencing payer policies.

Step 5: Submit Within Deadline
Ensure the appeal is submitted within the payer’s specified timeframe to avoid forfeiting the opportunity for reconsideration.

Step 6: Track and Follow Up
Monitor the appeal’s progress and communicate with the payer as needed to ensure timely resolution.

How To Prevent PR-247 Denials

Front-End Prevention

• Verify Patient Eligibility: Confirm deductible details and coverage limits before service delivery.
• Educate Front-End Staff: Train staff to recognize payer-specific policies regarding institutional claims.

Billing Best Practices

• Use Correct Claim Forms: Ensure professional services rendered in institutional settings are billed appropriately using CMS-1500 or UB-04 forms based on payer guidelines.
• Optimize Coding Accuracy: Implement checks to avoid coding errors that lead to denials.

Technology Solutions

• Automated Eligibility Verification: Utilize solutions like CombineHealth.ai’s platform to verify coverage details in real-time.
• Real-Time Claim Scrubbing: Leverage Adam to identify potential issues pre-submission and prevent denials.

In cases where denials do occur, Rachel (AI Appeals Manager) simplifies the appeals process, improving success rates and reducing turnaround times. By integrating advanced denial management tools, healthcare organizations can proactively reduce PR-247 denials and optimize their revenue cycle performance.

FAQs

Q1: What does PR-247 mean in medical billing?
PR-247 refers to a patient deductible applied to professional services rendered in an institutional setting and billed on an institutional claim.

Q2: Can PR-247 denials be appealed?
Yes, PR-247 denials can be appealed by providing proper documentation and addressing the denial reason within the payer’s deadline.

Q3: How long do I have to appeal?
Appeal deadlines vary by payer but typically range between 30-90 days from the denial notice date.

Q4: How can I prevent these denials?
Prevent PR-247 denials by verifying eligibility, submitting claims correctly, and utilizing advanced denial management solutions. See our complete guide on denial prevention.