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Back  RFI # 871: Group Code PR

Formal vs. Informal Help Informal Formal

Submitter

David Bennett

Description

The front matter of the 835 5010 version includes the group codes and their descriptions. "PI" and "CO" specifically state that the amount adjusted is not the patient's responsibility while "PR" states that the amount adjusted is the patient's responsibility. Our legal dept. has a concern with how that phrase might be interpreted in a court of law. It has been informally stated that this just means that the payer reporting this has met their obligation and the patient is now responsible for either making good on the difference or informing the provider of other resources for getting the payment. Can X12 post a written comment to either confirm or deny that the intent of "PR" is not to imply that the payer is stating that the patient must make up the difference between the amount charged and the amount paid by the payer issuing the 835? Language is extremely important when the courts are deciding the outcomes and the current language around this code is open to multiple interpretations.

Response

The intent of the PR Group Code - Patient Responsibility - is to relay to the provider that from the payer's perspective, based upon rules of the Insured's policy, this amount is the patient's (or Insured/responsible party) share of the payment to the provider for the services.
Submission 10/1/2009
Status Date 1/7/2010
Status F - Final
Primary References
Document 005010X221
Section1.10.2.4
Page?
Set ID835