PR-171: Payment Denied — Provider Type in This Facility Type

What Does PR-171 Mean?

PR-171 is less common and indicates the patient is responsible because they chose to receive the service from a provider-facility combination that is not eligible under their plan. This group code is appropriate when the patient was informed in advance and elected to proceed. The provider can bill the patient for the PR-171 amount.

When CARC 171 appears on a remittance, the payer is denying the claim because the specific combination of the provider type who performed the service and the facility type where it was performed is not eligible for reimbursement. This is distinct from CARC 170 (which flags the provider type alone) — CARC 171 specifically addresses the intersection of who performed the service and where it was performed.

Payers maintain rules about which provider types can bill specific services in specific facility settings. A service that a provider is authorized to perform in a hospital may not be reimbursable when the same provider performs it in an office or outpatient clinic. Similarly, a mid-level provider may be eligible to bill a service in a physician office (under incident-to rules) but not in a hospital outpatient department. The denial reflects the payer's determination that this particular provider-facility combination falls outside their reimbursement rules.

One of the most common and easily correctable causes of CARC 171 is an incorrect place of service (POS) code on the claim. If the POS code does not accurately reflect where the service was actually rendered, the payer's system may see a mismatch that does not actually exist. Before pursuing more complex solutions, always verify the POS code matches the actual facility. The RARC pairings are particularly informative with this code: N428 ('Not covered when performed in this place of service') points to a facility issue, while N95 ('This provider type may not bill this service') points to a provider issue, and both together confirm the dual-factor denial.

How to Resolve

Verify the place of service code, confirm provider-facility eligibility with the payer, and either correct the billing or rebill under an eligible provider-facility combination.

1. Verify advance notification Confirm an ABN or financial waiver was obtained documenting that the patient was informed of the provider-facility eligibility issue.
2. Transfer balance to patient Move the PR-171 amount to the patient responsibility ledger and issue a statement explaining the denial.
3. Offer alternatives If possible, offer to rebill under an eligible provider-facility combination or refer the patient to an eligible provider/facility for future services.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-171:

How to Prevent PR-171

• Inform patients when their plan restricts provider-facility combinations for specific services
• Verify eligibility during scheduling to direct patients to covered provider-facility combinations
• Obtain financial responsibility waivers when the provider-facility combination may not be eligible

Also Filed As

The same CARC 171 may appear with different Group Codes:

Related Denial Codes