PR 227 Denial Code Description, Causes and Fixes

In plain English, CARC 227 means the payer asked the patient, the policyholder or another responsible party for information and either never got it or got an incomplete answer. X12 publishes the official wording in its Claim Adjustment Reason Code list. Note who was asked: the patient or insured, not the provider. That single distinction is what makes PR-227 different from almost every other denial you work.

Here is the mechanism. When a payer suspects it may not be the responsible (primary) payer — or needs facts only the member has, such as whether an injury was the result of an auto accident — it does not deny the claim outright. Instead it mails the member a letter or questionnaire (a COB form, an accident-detail form, an 'other coverage' verification) and pends or denies the claim pending the reply. If the member ignores the letter, throws it away, or fills it out incompletely, the claim eventually denies with CARC 227. The denial is not saying your claim was wrong; it is saying the payer asked the patient a question and never got an answer.

In PR-227 the Group Code is PR. PR-227 pairs CARC 227 with Group Code PR (Patient Responsibility). This is where most billers go wrong: PR normally means 'bill the patient,' so a PR-227 looks like a patient balance and a statement goes out. But PR-227 is not a deductible, coinsurance, or copay — it is the payer holding the claim hostage until the patient supplies missing information. A statement does nothing to release it. The only thing that resolves PR-227 is the patient providing the requested information to the payer.

PR-227 is most likely where other coverage was not re-verified for a new patient, and on any service line with a possible third-party-liability angle (accidents, sports injuries, workers'-comp-adjacent visits). The claim can still be paid once the information arrives, but only if you work it as a patient-contact problem, not as a write-off or a balance bill.

Although CARC 227 always traces to the same root cause — the patient or insured did not answer the payer's request — the specific request behind it falls into a handful of recurring buckets. Identifying which one you are dealing with tells you exactly what to ask the patient to do.

1. Unanswered coordination-of-benefits (COB) questionnaire. An unanswered coordination-of-benefits (COB) questionnaire is a common PR-227 driver. Payers periodically send members a COB form asking whether they have other coverage (a spouse's plan, Medicare, retiree coverage). Until the member returns it, the payer will not coordinate benefits and pends/denies claims. Common companion RARCs: N245, MA92, or a plain 'contact the plan to update other-insurance information' alert.
2. Missing accident or injury detail. When a diagnosis suggests a possible accident (auto, slip-and-fall, sports injury), the payer sends an accident-questionnaire to determine whether auto, homeowners, or workers'-comp coverage is primary. No answer means PR-227 because the plan cannot rule out a liable third party.
3. Other-insurance / Medicare Secondary Payer (MSP) verification. For Medicare patients, an unanswered MSP questionnaire (working-aged, ESRD, disability, accident) produces this denial. Commercial plans run the equivalent 'is this plan primary?' check.
4. Student or dependent eligibility verification. Plans covering dependents over a certain age sometimes require the member to confirm full-time student status or continued dependent eligibility; an unreturned form pends the claim.
5. Incomplete response. The member did respond, but left a required field blank (no other-carrier policy number, no accident date, unsigned form), so the payer treats it as incomplete — the second half of the CARC 227 definition.

The common thread: in every case the lever is the patient, not your claim. The claim was clean. What is missing is an answer only the member can give the payer.

Because the missing information lives with the patient, the PR-227 workflow is a patient-contact workflow, not a claim-correction one. Do not resubmit a corrected claim first — there is nothing on the claim to correct. The claim will keep denying until the payer receives the answer from the member.

1. Read the 835 and identify what the payer actually requested. The CARC alone says 'information not provided.' The paired RARC (N245, MA92, N479, etc.) and the original payer letter tell you whether it is a COB form, an accident questionnaire, or an other-insurance verification. Pull the denial letter from the payer portal if you have access.
2. Call the payer to confirm what is outstanding and the deadline. Verify exactly which form is missing, whether the member can complete it by phone, the dedicated COB/MSP phone number, and how long the payer will hold the claim. Some payers let the member resolve a COB request in a single phone call.
3. Contact the patient with a specific, scripted ask. Do not send a generic statement. Call or send a plain-language letter that says: 'Your insurance company [payer] mailed you a form asking whether you have other insurance / details about an accident. Your claim cannot be paid until you answer it. Please call [payer COB number] and complete it.' Give them the exact phone number and what to say.
4. Offer to do it with them. One useful move is a three-way call or a warm handoff: the patient calls the payer's COB line with your staff on the line to walk them through it. A call lets the patient answer on the spot, which a mailed letter does not.
5. Confirm the payer received and processed the response, then resubmit. Once the member completes the form, call the payer to confirm the COB/MSP record is updated, then resubmit the claim (corrected-claim path or a simple resubmission per the payer). If the other coverage turned out to be primary, redirect the claim to the correct primary payer first, then bill this payer as secondary with the primary EOB.
6. Watch the timely-filing clock. PR-227 loops eat time. Document every patient contact and every payer call. If the window closes while you were waiting on the member, you may need a timely-filing exception with proof of original submission and a record of your good-faith follow-up.
7. Close the loop upstream. If PR-227 is recurring, the fix is front-end: capture other-coverage and accident information at registration, run an MSP questionnaire on every Medicare patient, and re-verify other coverage for established patients annually. Outsourced insurance eligibility verification and patient billing and collections services can own both the prevention and the patient-contact loop.

This is the most consequential question on a PR-227, because the Group Code is PR and PR usually means 'patient responsibility.' Here it does not mean a balance is owed.

You should not send the patient a bill for the denied charge. A PR-227 is not a deductible, coinsurance, or copay — it is the payer signaling that it cannot adjudicate the claim until the member supplies missing information. The 'patient responsibility' in PR-227 is the responsibility to answer the payer's request, not to pay the charge. If you balance-bill the patient for the full charge, you have not resolved anything: the claim is still pending information at the payer, and once the patient completes the form the claim will likely pay, leaving you to refund or reverse an inappropriate statement.

What you can and should do is ask the patient to act. Communicate clearly that their claim is stuck because their insurer needs them to complete a form, and that completing it is how the bill gets covered. Frame it as helping them avoid an out-of-pocket charge, not as a demand for payment.

The narrow exception: if the patient genuinely refuses to respond despite documented good-faith follow-up, and the payer ultimately closes the claim as the member's responsibility for non-cooperation, then — depending on your payer contract and state law — the charge may become the patient's responsibility. Even then, you must document the attempts, follow the payer's process, and confirm your contract permits it before billing. Treat that as a last resort after the claim is formally closed, not as the first move when the denial lands. The productive path is a phone call that gets the member to complete the form so the payer can adjudicate the claim.

PR-227, PR-31, and CO-16 all sound like 'we are missing something,' and billers routinely confuse them. They are three different problems with three different owners and three different fixes. Reading the code precisely is what keeps the worklist fast.

How to tell them apart fast. If the denial points at a form the patient was supposed to return, it is PR-227. If the payer cannot find the member in its system at all, it is PR-31. If a specific field on your claim is missing or invalid, it is CO-16 (read the RARC). PR-227 is the only one of the three where the lever is the patient and the claim itself is clean. Note that some payers route the same COB scenario to other codes — CO-22 (coordination of benefits) appears when the payer knows another carrier is primary, whereas PR-227 appears when the payer does not yet know and is still waiting on the member to tell it.

Like most CARCs, 227 travels with one or more Remittance Advice Remark Codes (RARCs) that narrow down exactly which patient-supplied information is missing. Always read the RARC as printed on your 835 — it tells you which form to chase. The table below decodes remark codes you may see with PR-227.

If the RARC points at other-insurance or COB (N245, MA92, N479, MA04, N4), the action is to resolve coordination of benefits with the member's help. If the payer letter asks for accident or injury details, the member must supply them. Build a RARC-to-script lookup in your denial worklist so a PR-227 auto-routes to the patient-contact queue with the right talking points already attached. For a fuller decoder of the N-remark family, see our N822 and N823 remark codes guide and the RARC glossary entry.

The CARC 227 logic is identical across payers — the member owes the payer an answer — but the form behind it and the resolution channel differ.

Medicare (MACs). On Medicare, an unreturned Medicare Secondary Payer (MSP) questionnaire is one cause of PR-227. Medicare must rule out working-aged coverage, ESRD coordination, disability coverage, and accident/liability before it pays primary. When the beneficiary has not completed the MSP screening (often collected at registration via the CMS MSP questionnaire), claims pend and then deny. The fix: have the beneficiary or your front desk complete the MSP questionnaire and, if another payer is primary, bill that payer first and Medicare as secondary using the primary EOB. The Benefits Coordination & Recovery Center (BCRC) is the channel for updating Medicare's COB record.

Medicaid (state programs and MCOs). Because Medicaid is the payer of last resort by federal law, state programs and MCOs pursue third-party liability (TPL) and other coverage. PR-227-type denials surface when the member has not confirmed or denied other coverage on file. Each state program and MCO has its own TPL/COB process and portal — verify the state's companion guide. The highest-yield prevention is capturing and verifying all other coverage at every Medicaid visit, since eligibility and other-coverage status change frequently.

Commercial payers. Commercial PR-227s can involve the annual or triggered COB questionnaire (especially for members with a spouse's plan or dual employer coverage) and accident questionnaires on injury diagnoses. Many commercial payers let the member resolve COB by phone with the plan's coordination-of-benefits unit; some require the form by mail or portal. Confirm the dedicated COB number and whether a phone update is sufficient before you ask the patient to act — a single guided phone call can resolve a commercial PR-227.

Across all three, the universal accelerant is front-end capture: an MSP questionnaire on every Medicare patient, an other-coverage and accident screen at registration, and annual re-verification of other coverage for established patients catch PR-227 triggers before a claim ever denies.

PR-227 shares the denial worklist with several adjacent codes that have overlapping causes. Knowing which is which prevents misrouting a clean claim into a correction queue it does not belong in.

CARC 22 — Another payer may be responsible under coordination of benefits. The next-door neighbor of PR-227. The difference: with CO-22 the payer already knows another carrier is primary and is telling you to bill them; with PR-227 the payer does not yet know and is waiting on the member to confirm. Once the member returns the COB form, a PR-227 can resolve into a CO-22 redirect. See our CO-22 coordination-of-benefits explainer.

CARC 31 — Payer cannot match the patient to a member record. Easy to confuse with PR-227 because both can carry an other-insurance RARC, but PR-31 means the member is not found in the eligibility file at all, while PR-227 means the member is found but owes the payer information. See our PR-31 denial code guide.

CARC 16 — The claim itself is missing data or has a submission or billing error. When the missing element is on the claim (a field you can fix) rather than information the patient must supply, the denial is CO-16, and the fix is to read the RARC and correct the field — not to contact the patient.

CARC 109 — Not this payer's claim; bill the payer that covers it. Sometimes the COB answer reveals this payer was never the right one; the claim then belongs to the primary carrier entirely.

CARC 23 — Reflects what an earlier payer already paid or adjusted. Appears on secondary claims once COB is resolved and the primary has paid — the normal, expected downstream of a correctly worked PR-227.

The discipline that keeps a PR-227 worklist fast is recognizing at intake that the lever is the patient, routing the denial straight to a patient-contact queue, and only treating it as a billing correction if the member's response reveals a true claim or COB redirect.

PR-227 is rarely a true 'appeal' — it is a resolve-and-resubmit. You are not disputing the payer's decision; you are supplying the information that was missing. But you do need a documented, repeatable process, and occasionally a written submission when the member has completed the form and the payer still has not released the claim.

Patient outreach script (call or letter):

'Hello [patient name], this is [practice] calling about your visit on [date]. Your insurance company, [payer], mailed you a form asking whether you have any other insurance / for details about an accident. Your claim is on hold and cannot be paid until you answer it. Please call [payer COB/MSP phone number] and complete the form — we are happy to stay on the line with you while you do it. Once it is done, your insurance can process the claim.'

Resubmission cover note (when the form is completed but the claim is still denied):

'Re: Claim [number], Member [ID], DOS [date]. This claim previously denied CARC 227 (the member had not fully answered your plan's request for information). The member completed the [COB / MSP / accident] questionnaire with your plan on [date] (confirmation [#] / via [phone/portal]). The coordination-of-benefits record now reflects [this plan is primary / other carrier is primary]. We are resubmitting for adjudication [as primary / as secondary with the primary EOB attached]. Please process accordingly. Supporting documentation enclosed: original claim, remittance advice, and confirmation of the completed questionnaire.'

Attach: the original claim, the 835/EOB showing the PR-227, proof the member completed the request (confirmation number, portal screenshot, or dated call note), and — if this payer is now secondary — the primary payer's EOB.

Keep a dated log of every patient contact and payer call on each PR-227. That log is your timely-filing protection if the window closes while you were waiting on the member, and it is the documentation you need if a stubborn case ultimately has to be escalated. For volume practices, outsourced denial management services and accounts receivable follow-up can own the patient outreach, the COB resolution, and the resubmission end to end. If PR-227s have already piled up past routine follow-up, working that backlog is a one-time cleanup of aged A/R, which our medical billing collection services run as a defined project.