PR-106: Patient Payment Option Not in Effect
The patient's payment option lapsed and they owe the charges. Verify the PR assignment is correct before billing — if the lapse was a payer error, contact the payer. If the patient's election genuinely expired, collect from the patient.
What Does PR-106 Mean?
PR-106 means the patient bears financial responsibility because their chosen payment option was not in effect on the date of service. This typically occurs when the patient failed to maintain their enrollment, missed premium payments, or let their elected payment option lapse. The provider can bill the patient for the denied amount after confirming the PR assignment is correct.
CARC 106 fires when the payer's system determines that the payment option or coverage election the patient chose is not currently in effect for the date of service. This typically involves situations where a patient enrolled in a specific plan type — such as an HMO, Medicare MSA, capitated arrangement, or a particular payment plan — but that election expired, lapsed, or was never properly activated in the payer's records.
This denial is distinct from a general eligibility denial. The patient may have active coverage with the payer, but the specific payment arrangement under which the claim was submitted does not match the patient's current election. For example, a patient who switched from a fee-for-service plan to an HMO during open enrollment may trigger CARC 106 if the provider bills under the old arrangement.
The financial impact depends on the Group Code. CO-106 means the provider must absorb the denied amount as a contractual write-off, typically because the billing mismatch is a provider-side issue. PR-106 shifts the cost to the patient, usually because the patient's own failure to maintain their elected payment option caused the coverage gap. Always verify which group code applies before taking action, as the resolution path differs significantly.
Common Causes
| Cause | Frequency |
|---|---|
| Patient failed to maintain selected payment option The patient chose a specific coverage option or payment plan but did not maintain the required enrollment, premium payments, or other conditions to keep the option active, resulting in patient liability for services rendered | Most Common |
| Patient's coverage election changed without notification The patient changed their payment option or coverage election during an open enrollment period but the provider was not informed, leading to claims denied because the previous election is no longer valid | Common |
How to Resolve
Verify the patient's current payment election status, determine whether the denial reflects a genuine lapse or a system error, and either resubmit to the correct arrangement or collect from the patient.
- Confirm PR assignment is correct Verify with the payer that the PR-106 assignment is accurate and the patient's payment option was genuinely not active, rather than a payer system error that should have been CO.
- Review patient enrollment records Check whether the election lapsed due to patient action (missed payments, failed to re-enroll) or a payer processing error.
- Assist patient if payer error If the patient's election was active but not reflected in the payer's system, help the patient contact the payer to correct the enrollment records and resubmit the claim.
- Bill the patient if valid If the PR assignment is correct and the patient's election genuinely lapsed, bill the patient with documentation explaining why their payment option was not in effect.
PR-106 indicates the patient's payment option was not in effect and the patient bears financial responsibility. If the patient disputes the lapse, they should contact the payer to resolve enrollment issues. The provider should collect from the patient or assist them in rectifying the enrollment before resubmitting.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-106:
| RARC | Description |
|---|---|
| N30 | Patient not eligible for this service on this date Verify patient's enrollment status; if lapsed, bill patient after confirming PR assignment → |
How to Prevent PR-106
- Educate patients about maintaining their selected payment options and the consequences of letting elections lapse
- Verify coverage eligibility at every visit, particularly for patients with complex payment arrangements
- Provide patients with advance notice of upcoming enrollment deadlines or premium due dates when possible
General Prevention
- Educate patients about the importance of maintaining their selected payment options and notifying the provider of any changes to their coverage elections
- Verify coverage eligibility at every visit, especially for patients with complex payment arrangements or multiple coverage options
- Provide patients with clear information about potential financial responsibility if their payment option lapses
Also Filed As
The same CARC 106 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code-carcs
- https://droidal.com/blog/medical-billing-denial-codes/
- https://practiceperfectss.com/list-of-denial-codes-in-medical-billing/
- Codes maintained by X12. Visit x12.org for official definitions.