PR-31 Denials Explained: How to Identify, Appeal, and Prevent Them

Denial codes are a persistent challenge for healthcare revenue cycle management (RCM) teams, impacting cash flow, operational efficiency, and overall revenue integrity. One particularly common denial code, PR-31, occurs when a patient cannot be identified as insured by the payer. This type of denial can often be prevented but, when it arises, requires efficient resolution to avoid financial losses.

In this article, we’ll explore the PR-31 denial code in detail, including what it means, how it compares to similar denials, the common causes, and actionable steps to appeal and prevent it.

What Is a PR-31 Denial?

The PR-31 denial code indicates that the payer could not identify the patient as their insured, making the claim the patient’s financial responsibility. The prefix "PR" stands for "Patient Responsibility," meaning the financial burden falls on the patient, not the provider or payer. This denial often arises from errors in patient information or coverage verification, which can cause delays in claim payment or outright rejections.

Understanding the prefix is critical when addressing denial codes:
- PR (Patient Responsibility): Denials where the patient is responsible for payment.
- CO (Contractual Obligation): Denials involving pre-agreed contractual terms between provider and payer.
- OA (Other Adjustment): Denials related to non-standard adjustments.

For PR-31, the focus is on confirming the patient’s insurance eligibility and ensuring accurate coverage details.

Comparison: PR-31 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-31	Patient Responsibility	Patient cannot be identified as our insured.	Patient
CO-22	Contractual Obligation	Services exceed coverage limits.	Provider
OA-7	Other Adjustment	The procedure is not covered under the policy.	Provider

While PR-31 denials center on patient identification and eligibility issues, CO-22 and OA-7 often arise due to policy limitations or lack of coverage for specific services. PR-31 typically requires verifying patient details, while the latter may involve contract or policy reviews.

Common Causes of PR-31 Denials

1. Incomplete or Incorrect Patient Information: Errors in demographic details like name, date of birth, or insurance ID can lead to eligibility mismatches.
2. Failure to Verify Coverage: Skipping real-time eligibility checks can result in claims being submitted for patients without active coverage.
3. Policy Termination or Lapse: If a patient’s insurance policy has expired or been canceled, the payer cannot match the claim to an active plan.
4. Coordination of Benefits (COB) Issues: Multiple insurance policies without proper coordination can lead to confusion about primary coverage.
5. Data Entry Errors: Mistakes during claim submission, such as transposed numbers in the insurance ID, can trigger denials.

Impact on Revenue Cycle Teams

PR-31 denials can have far-reaching consequences for healthcare organizations, affecting both financial outcomes and operational efficiency.

Financial Impact:

• Revenue loss due to denied claims requiring rework.
• Increased accounts receivable days and delayed cash flow.
• Write-offs when appeals are unsuccessful or deadlines are missed.
• Higher costs associated with denial management and appeals.

Operational Impact:

• Increased workload for staff managing denials and appeals.
• Need for comprehensive knowledge of payer policies and eligibility checks.
• Greater coordination required between billing, coding, and clinical teams.
• Ongoing monitoring of denial trends to identify root causes.

To address these challenges, RCM teams should implement robust denial management solutions, such as CombineHealth.ai’s AI-powered platform. Adam (AI Denial Manager) helps teams track and resolve PR-31 denials with efficiency, reducing revenue leakage and operational strain.

Steps To Appeal a PR-31 Denial

Efficient appeals are critical to recovering revenue from PR-31 denials. Follow these steps to maximize success:

Step 1: Review the Denial Notice
Carefully examine the Explanation of Benefits (EOB) or Remittance Advice (RA) to confirm the denial reason and identify the specific issue.

Step 2: Gather Documentation
Collect all relevant documentation, including the patient’s insurance card, demographic details, and prior eligibility checks.

Step 3: Verify Eligibility
Contact the payer to confirm the patient’s eligibility and ensure the information matches the claim submission.

Step 4: Prepare Appeal Letter
Draft a concise, professional appeal letter outlining the denial reason, corrective actions taken, and supporting evidence.

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 status of the appeal and maintain communication with the payer to address any additional requests promptly.

How To Prevent PR-31 Denials

Proactive measures are key to minimizing PR-31 denials. Focus on prevention through front-end processes, billing practices, and leveraging technology solutions.

Front-End Prevention

• Conduct real-time insurance eligibility checks at the time of scheduling and registration.
• Verify and update patient demographic and insurance details at every visit.

Billing Best Practices

• Perform thorough claim edits before submission to catch errors in patient or insurance data.
• Establish workflows for COB scenarios to ensure accurate primary and secondary payer identification.

Technology Solutions

• Use automated eligibility verification tools, such as CombineHealth.ai’s platform, to confirm coverage in real-time.
• Employ claim scrubbing technology to identify and correct errors before submission.

CombineHealth.ai’s intelligent tools, including Rachel (AI Appeals Manager), streamline denial prevention and appeals, reducing rework and improving success rates. By automating eligibility verification and integrating denial management, RCM teams can significantly reduce the occurrence of PR-31 denials.

FAQs

Q1: What does PR-31 mean in medical billing?
PR-31 indicates that the patient cannot be identified as insured, making the claim the patient’s responsibility.

Q2: Can PR-31 denials be appealed?
Yes, PR-31 denials can be appealed by verifying patient eligibility and submitting corrected claims or supporting documentation.

Q3: How long do I have to appeal?
Appeal deadlines vary by payer but are typically within 30-90 days from the denial date. Check the payer’s specific requirements.

Q4: How can I prevent these denials?
Ensure accurate patient information, verify insurance eligibility in real-time, and use automated tools like CombineHealth.ai to prevent errors. See our complete guide on denial prevention.
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