Denial Code PR-31: Managing Patient Deductible Responsibility

Denial Code PR-31 often presents a common challenge in healthcare billing. This code indicates that a claim has been denied because the patient’s deductible has not been met. Effectively managing PR-31 denials is crucial for ensuring your practice gets reimbursed and for navigating patient responsibilities. In this blog, we’ll delve into what PR-31 means, provide actionable strategies for addressing these denials, and share tips for preventing them in the future.

What is Denial Code PR-31?

Denial Code PR-31 signifies that the claim was denied due to the patient’s deductible not being met. This means that the services provided are covered by the patient’s insurance plan, but the patient has not yet fulfilled their deductible requirement for the current plan year.

Why Does PR-31 Matter?

PR-31 denials can impact your practice’s revenue cycle by causing delays in payment and increasing administrative tasks. Addressing these denials efficiently is essential for managing patient accounts and ensuring that your practice is compensated for the services rendered.

Deconstructing a PR-31 Denial: What Went Wrong and How to Fix It

Example:

• Initial Billing:some text
  • CPT 97530: Therapeutic Activities

• Outcome: The claim was denied under PR-31 because the patient’s deductible had not been satisfied.

Remedy:

1. Verify Deductible Status: Check the patient’s insurance benefits to confirm the status of their deductible and the amount remaining.
2. Inform the Patient: Communicate with the patient about their outstanding deductible and any financial responsibility they have.
3. Adjust Billing: Update the patient’s account to reflect their financial responsibility and collect the appropriate amount.
4. Resubmit the Claim: If applicable, adjust the claim or submit it with the appropriate adjustments after collecting patient responsibility.

• Corrected Billing:some text
  • CPT 97530: Therapeutic Activities (with notes on patient responsibility and any adjustments made)

Actionable Steps: How to Address a PR-31 Denial

1. Analyze the Denial: Review the Explanation of Benefits (EOB) or Remittance Advice (RA) to understand that the claim was denied due to the patient’s unmet deductible.
2. Confirm Deductible Amount: Verify the patient’s deductible status and the amount they owe to the insurance provider.
3. Communicate with the Patient: Notify the patient about their deductible and discuss payment options.
4. Collect Patient Responsibility: Ensure that the patient pays the outstanding deductible amount and update their account accordingly.
5. Resubmit or Adjust Claims: If necessary, make adjustments to the claim and resubmit it for payment.

Common Causes of PR-31 Denials

1. Unmet Deductible: The patient has not yet reached their deductible limit for the insurance plan year.
2. Incorrect Benefit Information: Errors in verifying patient benefits or deductible status.
3. Miscommunication with Patients: Lack of clear communication with patients regarding their financial responsibilities.

Proactive Prevention: Avoiding PR-31 Denials

Pre-Claim Submission Checklist:

• Verify Deductibles: Check patient deductible statuses before providing services and inform patients of their financial responsibilities.
• Confirm Insurance Details: Ensure that insurance benefits and deductible amounts are accurate and up-to-date.
• Communicate with Patients: Provide clear information to patients about their deductible and potential out-of-pocket costs before treatment.

Training and Best Practices:

• Train billing and administrative staff on how to verify and handle deductible information.
• Develop processes for effective patient communication regarding financial responsibilities and deductibles.

Technology and Tools:

• Utilize patient eligibility verification tools to check deductible status and benefits before service.
• Implement billing software that integrates with insurance providers to streamline verification and updates.

Conclusion: Efficient Management of PR-31 Denials to Maintain Revenue Integrity

Denial Code PR-31 can be challenging, but with a proactive approach to managing patient deductibles and clear communication, your practice can effectively address these denials. By verifying deductible statuses, collecting patient responsibilities, and leveraging technology, you can minimize the impact of PR-31 denials and ensure smooth revenue cycle operations.

Streamline Your Billing with SPRY

Navigating PR-31 and other billing complexities can be simplified with the right tools. SPRY’s advanced billing software helps you verify patient benefits, manage deductible information, and streamline your billing processes. Ready to enhance your revenue cycle management? Schedule a demo with SPRY today and discover how our solutions can support your practice’s financial health.

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