PR-35 Denials Explained: How to Identify, Appeal, and Prevent Them

Denial codes like PR-35 represent a common challenge for healthcare revenue cycle teams, often leading to lost revenue and operational inefficiencies. PR-35 denials occur when a patient’s lifetime maximum benefit limit is exhausted, shifting financial responsibility to the patient. Understanding this denial code is crucial for healthcare organizations aiming to mitigate revenue leakage and optimize operations.

In this article, you’ll learn what PR-35 denials mean, how they differ from similar codes, common causes, their impact on RCM teams, and actionable steps to appeal and prevent them.

What Is a PR-35 Denial?

PR-35 is a denial code indicating that the lifetime benefit maximum for a patient’s insurance coverage has been reached. The prefix “PR” stands for “Patient Responsibility,” meaning the financial burden falls on the patient. Other common prefixes include “CO” (Contractual Obligation), where the payer is not liable due to contractual terms, and “OA” (Other Adjustment), which reflects miscellaneous adjustments or denials.

When a claim is denied with PR-35, the provider cannot bill the payer further, as the patient has exhausted their benefits. This denial often results in the need for detailed follow-up with both the patient and payer to clarify coverage limits and explore options.

Comparison: PR-35 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-35	Patient Responsibility	Lifetime benefit maximum has been reached.	Patient
PR-96	Patient Responsibility	Non-covered charges under patient’s policy.	Patient
CO-119	Contractual Obligation	Benefit maximum for this service period exceeded.	Payer

While PR-35 and PR-96 both indicate patient responsibility, PR-35 is specific to lifetime benefit maximums, whereas PR-96 applies to non-covered charges. CO-119, on the other hand, pertains to benefit limits within a specific service period and highlights payer liability.

Common Causes of PR-35 Denials

1. Exhausted Lifetime Benefits: The patient’s insurance coverage has reached its maximum allowable limit for lifetime benefits.
2. Lack of Eligibility Verification: Failure to verify benefit limits during the pre-registration process.
3. Incorrect Coding or Billing: Submission of claims without awareness of remaining benefits or proper coordination with the payer.
4. Miscommunication with Patients: Patients unaware of their benefit limits may lead to disputes or delayed payments.

Impact on Revenue Cycle Teams

PR-35 denials present significant financial and operational challenges for healthcare organizations.

Financial Impact:
- Direct revenue loss when claims are denied, requiring rework.
- Increased accounts receivable days as appeals prolong payment resolution.
- Risk of write-offs if denied claims are not appealed within payer deadlines.
- Additional costs for denial management processes, including staff training and follow-up.

Operational Impact:
- Staff diverted from other revenue cycle functions to manage denials.
- Need for expertise in payer policies and benefit structures.
- Greater collaboration required between billing, coding, and clinical teams.
- Tracking denial trends to identify recurring issues and improve processes.

To address these challenges, healthcare organizations can leverage CombineHealth.ai’s AI-powered platform. Adam (AI Denial Manager) automates denial tracking, analysis, and resolution, helping teams resolve PR-35 denials efficiently and reduce their financial impact.

Steps To Appeal a PR-35 Denial

Step 1: Review the Denial Notice
Carefully examine the explanation of benefits (EOB) or remittance advice to understand the specific reason for the denial.

Step 2: Gather Documentation
Collect all necessary supporting documents, including the patient’s insurance policy details, medical records, and proof of services provided.

Step 3: Verify Eligibility
Confirm the patient’s coverage limits with the payer and ensure the denial aligns with the policy terms.

Step 4: Prepare Appeal Letter
Draft a comprehensive appeal letter that includes patient information, claim details, supporting evidence, and a clear explanation of why the denial should be overturned.

Step 5: Submit Within Deadline
Adhere to the payer’s appeal submission timeline to avoid missed opportunities for reconsideration.

Step 6: Track and Follow Up
Monitor the status of the appeal and maintain communication with the payer until a resolution is reached.

How To Prevent PR-35 Denials

Front-End Prevention

• Conduct thorough eligibility verification during patient registration to identify benefit limits upfront.
• Educate patients about their coverage, including lifetime maximums, to avoid surprises.

Billing Best Practices

• Implement regular audits to ensure accurate coding and documentation.
• Coordinate with payers to confirm benefit limits before claim submission.

Technology Solutions

• Utilize CombineHealth.ai’s automated tools for real-time eligibility checks and claim scrubbing to reduce errors.
• Deploy Rachel (AI Appeals Manager) to streamline denial appeals and improve success rates.

By leveraging these strategies, healthcare organizations can proactively address PR-35 denials, minimizing their occurrence and impact on operations.

FAQs

Q1: What does PR-35 mean in medical billing?
PR-35 indicates that a patient’s lifetime benefit maximum has been reached, making them financially responsible for additional costs.

Q2: Can PR-35 denials be appealed?
Yes, with proper documentation and adherence to payer guidelines, PR-35 denials can be appealed.

Q3: How long do I have to appeal?
Appeal deadlines vary by payer but typically range from 30 to 90 days. Check the denial notice for specific timelines.

Q4: How can I prevent these denials?
Robust eligibility verification, proper coding practices, and advanced denial management tools can help prevent PR-35 denials. See our complete guide on denial prevention.