PR227 Denial Code - How to resolve and AR Caller steps? (2024)

June 28, 2024bhvnbc1992

Insurance company will deny the claim with PR227 denial code

• If the information requested from the patient or insured or the responsible person was not provided or
• the information was insufficient or incomplete to reimburse the claim.

This could include missing personal details, incorrect insurance information, or failure to provide necessary documentation. To resolve this issue, the individual responsible should provide the requested information in a complete and accurate manner to ensure that the claim is processed successfully.

The above denial occurs when the insurance company requires the following information from the patient:

• Coordination of Benefits details
• Insufficient medical history from patient
• Accident information details
• Pre-existing condition information
• Consent form. etc.,

Insurance companies typically send a written request directly to the patient or insured individual, which may also include a section for the responsible party if necessary. This request will outline the specific information needed in order to properly process and reimburse the claim. It is important for the patient or insured individual to provide the requested information in a timely manner to avoid any delays in the claims process.

How to handle PR227 denial code?

• When an insurance company denies a claim with the PR227 denial code, the initial step is to carefully review the previous notes to determine if the requested information has indeed been submitted by the patient.
• When previous notes indicate that a patient has responded with the required information to the insurance company, it is crucial to follow a structured process to ensure timely and effective claim resolution. Once the patient has provided the necessary details, it is essential to allow an appropriate amount of time for the insurance company to process the information and respond.
• If no previous notes exist in the system for the Date of Service (DOS), it is crucial to check whether previous claims have been paid or not. If the previous claims have already been paid, the next step is to determine when the insurance company requested information from the patient.
• In cases where paid claims were previously denied for the same reason, and the insurance company subsequently paid after receiving the requested information from the patient, it is advisable to contact the insurance claims department to ask for a reprocessing of this date of service. Referencing the fact that the patient has already submitted the necessary information in the previous claims and also payments have been received for those services.
• When an insurance company requests information from the current date of service (DOS), it is important to promptly reach out to the insurance claims department to verify whether the patient has updated the requested information.
• If patient has recently updated the requested information, it is imperative to allow sufficient time for processing before following up with the insurance company.
• If insurance company has sent a letter to a patient that has surpassed the 30-day mark without a response. Then, we need to formally request the insurance company to resend a letter soliciting the required details
• Suppose if patient has not responded to multiple letters, then we need to bill patient.

AR caller on call steps for PR227 denial code:

1. Get the denial date and reason for the denial from the insurance representative (Could you please provide me the denial date and also the cause for denial?)
2. If claim denied with PR227 denial code (Could you please provide me, what information insurance company looking from patient?)
3. Check if any letter sent to patient (May I know any letter sent to the patient requesting the same info?)
4. If they have already sent a letter to patient (May I know when and how many times you have sent letter?)
5. Check if patient has already responded for the letter (Did patient responded for the letter sent?)
6. If yes, then request rep to send the claim back of reprocessing.
7. If no, then request to send one more letter if it crossed more than 30 days.
8. Finally get the Claim# & Cal-reference#

It is crucial for healthcare providers and patients to understand the specific details required by the insurance company to avoid claim denials and delays in payment. Failure to provide the necessary information can result in challenges in receiving the rightful reimbursem*nt for healthcare services rendered. Health providers should communicate clearly with patients about the documentation and details needed for successful claim submission to prevent PR227 denials.