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PR-275 Denial Code: Prior Payer's Patient Share Not Covered

PR-275 means this secondary (or tertiary) payer won't cover the patient responsibility left by the prior payer, such as deductible, coinsurance, or co-payment. X12 allows it only with group PR, so the patient generally owes that amount.

Quick facts

Code
PR-275 (CARC 275)
Status
Active In use since November 1, 2015.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • PR (Patient Responsibility): The only group X12 allows for CARC 275. The prior payer's cost-sharing stays with the patient because this payer doesn't cover it.
Official description
Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What PR-275 means

CARC 275 says the prior payer’s (or payers’) patient responsibility — deductible, coinsurance, co-payment — is not covered. It appears on secondary or tertiary remittances. The primary payer processed the claim and left some cost-sharing with the patient. You sent that balance to the next payer, hoping it would pay. The next payer is saying it won’t, and X12 restricts the code to group PR: the patient keeps that responsibility.

This is common when the secondary plan doesn’t cover the service, when it coordinates benefits in a way that leaves nothing to pay, or when its benefits exclude cost-sharing from other plans. It often comes with remark N536, which says the payer isn’t changing the prior payer’s patient responsibility and you may collect it.

Example: a patient’s primary plan applies $40 to coinsurance. The secondary plan uses non-duplication of benefits: since the primary already paid at least what the secondary would have paid, the secondary pays nothing and returns PR-275 for the $40. The patient owes the $40.

Common causes

  • Secondary plan doesn’t cover the service at all.
  • Non-duplication or carve-out COB methods that leave nothing for the secondary to pay.
  • Plan design that excludes coverage of another plan’s cost-sharing.
  • Incorrect COB data on the secondary claim, such as missing primary adjustments.

How to handle it

  1. Check the secondary claim’s COB data for correct primary payment and adjustments. If wrong, correct and resubmit (resubmission code 7 in box 22).
  2. Look for a tertiary payer and bill it if one exists.
  3. Check patient protections. For Qualified Medicare Beneficiaries and certain Medicaid-eligible patients, federal and state rules may limit billing of Medicare cost-sharing (CARC 303 addresses the QMB situation).
  4. Bill the patient for the PR-275 amount when no protections apply.

How to prevent problems

  • Verify all coverage and the order of benefits at each visit.
  • Send complete primary adjudication data on secondary claims.
  • Estimate patient responsibility when the secondary plan is known to coordinate with non-duplication.
  • Flag QMB and dual-eligible patients in your system. See eligibility and COB denials.

Remark codes that may appear with PR-275

  • N536 (We are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us.): The payer isn't changing the prior payer's patient responsibility, which you may collect, because this service isn't covered by it.
  • OA-23 (The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)): The impact of the prior payer's adjudication, shown on most secondary claims.
  • CO-276 (Services denied by the prior payer(s) are not covered by this payer.): Services the prior payer denied aren't covered by this payer either.
  • CO-303 (Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid…): A similar rule specific to Qualified Medicare Beneficiaries, whose cost-sharing is subject to billing protections.
  • PR-1 / PR-2 / PR-3 (Deductible, coinsurance, and co-payment amounts.): The primary payer's cost-sharing amounts that PR-275 leaves with the patient.

PR-275 FAQ

Why won't the secondary pay the primary's coinsurance?

The secondary plan may not cover the service, may coordinate in a way that leaves nothing to pay (such as non-duplication of benefits), or may exclude the primary's cost-sharing under its rules.

Can I bill the patient for PR-275?

Generally yes, since X12 limits this code to PR. The exception is patients with billing protections, such as Qualified Medicare Beneficiaries, which have separate rules. Check before billing.

Should I check anything before billing?

Confirm the primary's patient responsibility amounts were reported correctly on the secondary claim, and whether a tertiary payer exists. Errors in the COB data can cause a secondary to deny cost-sharing it would otherwise cover.

How is PR-275 different from PR-276?

CARC 275 is about the prior payer's cost-sharing on services it covered. CARC 276 is about services the prior payer denied, which this payer also won't cover.