PR-170: Payment Denied — Provider Type Not Eligible

What Does PR-170 Mean?

PR-170 shifts the financial responsibility to the patient. In the Medicare context, this occurs when a valid ABN was obtained and the patient was informed that the provider type might not be eligible to bill the service. The patient elected to proceed and is now responsible for the charges. For commercial payers, PR-170 may appear when the patient's plan restricts which provider types can deliver certain services and the patient chose a non-eligible provider.

When CARC 170 appears on a remittance, the payer has denied the claim because the type of provider who performed or billed the service is not authorized to receive payment for that specific procedure. This is not a question about whether the service was medically necessary or properly coded — the payer is saying that the provider's credentials, specialty, or enrollment status does not qualify them to bill this particular CPT or HCPCS code.

Payers maintain lists of which provider types are authorized for specific services. A nurse practitioner may be able to bill evaluation and management codes but not certain surgical procedures. A physical therapist may be restricted from billing certain diagnostic services. These restrictions vary significantly between payers and are often rooted in state scope-of-practice laws, payer contracts, and Medicare's provider type requirements. The RARC most frequently paired with this code is N95 ('This provider type/provider specialty may not bill this service'), which confirms the provider-type mismatch.

The most common resolution involves correcting the billing to use the right provider's NPI. In many cases, the service was legitimately provided but billed under the wrong provider — for example, a mid-level provider billed independently when the service should have been billed incident-to a supervising physician. In other cases, the rendering provider's enrollment with the payer may need to be updated to reflect the correct specialty or credentials. Always check the 835 Loop 2110 REF Healthcare Policy Identification Segment, which points you directly to the payer policy that triggered the denial.

Common Causes

How to Resolve

Identify the provider type restriction, verify credentials and enrollment, and either correct the billing identifiers or rebill under an eligible provider.

1. Verify advance notification Confirm a valid ABN or financial responsibility waiver was obtained before the service. Without it, you may not be able to collect from the patient.
2. Transfer balance to patient Move the PR-170 amount to the patient responsibility ledger and send a clear statement explaining the denial reason.
3. Offer to rebill under eligible provider If the service can be rebilled under an eligible provider type, offer this option to the patient before pursuing collection.
4. Follow standard patient collections Enter the balance into your patient collections workflow with payment options.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-170:

How to Prevent PR-170

• Inform patients when their plan restricts provider types for specific services
• Obtain an ABN or financial waiver before providing services when provider eligibility is uncertain
• Check provider type eligibility during scheduling so patients can be directed to eligible providers

Also Filed As

The same CARC 170 may appear with different Group Codes:

Related Denial Codes