PR-58: Invalid Place of Service / Treatment Setting Mismatch

What Does PR-58 Mean?

PR 58 shifts financial responsibility to the patient because their plan restricts where certain services can be performed, and the service was rendered at a non-covered location. This commonly occurs when a patient receives treatment at an out-of-network facility or at a facility type that their plan does not cover for the specific service. The provider can bill the patient for the full charge.

CARC 58 signals that the payer has flagged a mismatch between the service billed and the location where it was performed. In practice, this denial is most often caused by a wrong Place of Service (POS) code on the CMS-1500 or 837P claim. The billing staff selected POS 11 (Office) when the service was rendered in POS 22 (On Campus Outpatient Hospital), or vice versa. This is a correctable billing error with a straightforward fix.

However, CARC 58 is not always a simple coding mistake. It can also mean the payer has determined that the service should not have been performed in the billed setting at all. For example, a payer may deny an inpatient admission with CARC 58 if they believe the procedure could have been safely performed in an outpatient or ambulatory surgery center setting. In these cases, the denial is about clinical appropriateness of the treatment setting, not about the code on the claim form.

The group code tells you which scenario you are dealing with. CO 58 means the provider bears the financial responsibility — check the POS code first, and if it is correct, prepare for a clinical appeal demonstrating why the treatment setting was medically necessary. PR 58 means the patient is responsible, which typically occurs when the service was performed at an out-of-network facility or a location the patient's plan does not cover for the specific service.

Common Causes

How to Resolve

Verify whether the POS code is correct. If wrong, fix and resubmit. If correct, appeal with clinical documentation supporting the treatment setting.

1. Verify facility restrictions Check the patient's plan to confirm which facility types are covered for the specific service. Determine if out-of-network benefits apply at a reduced rate.
2. Notify the patient Inform the patient of the denial, explain the facility restriction, and provide a clear statement of the amount owed.
3. Assist with appeal if appropriate If the treatment setting was the only available option for the service (e.g., no in-network facility offers the procedure), assist the patient with a member-level appeal.

How to Prevent PR-58

• Verify the patient's network and facility restrictions during eligibility checks before scheduling.
• Inform patients when their plan requires services at specific facility types.
• Provide referrals to in-network facilities when the patient's plan requires it.

General Prevention

• Verify the patient's network and facility restrictions during eligibility checks before scheduling services.
• Inform patients when services must be performed at a specific type of facility under their plan.

Also Filed As

The same CARC 58 may appear with different Group Codes:

Related Denial Codes