PR-61: Second Surgical Opinion Not Obtained

What Does PR-61 Mean?

PR 61 shifts financial responsibility to the patient because they did not comply with their plan's requirement to obtain a second surgical opinion before the procedure. The patient may not have been aware of the requirement, or they may have chosen not to pursue the second opinion. In some cases, the patient obtained a second opinion that did not support the surgery and proceeded anyway, triggering the denial.

CARC 61 appears when a payer denies a surgical claim because the insurance plan required a second surgical opinion before the procedure was performed, and that requirement was not met. Second surgical opinion programs are designed to reduce unnecessary surgeries by having an independent physician confirm that the proposed procedure is medically necessary. While these programs were more common in earlier decades, many commercial plans and some self-insured employer plans still mandate second opinions for elective surgeries.

The denial can trigger for several reasons: the second opinion was never obtained, it was obtained from a provider not on the payer's approved list, the documentation was not submitted with the claim, or the second opinion did not support the surgical recommendation and the patient proceeded anyway. The last scenario is particularly challenging because some payers will deny coverage when the independent reviewer did not agree with the original surgical recommendation.

The group code determines the financial impact. CO 61 puts the burden on the provider, who should have ensured the second opinion requirement was met before scheduling the surgery. PR 61 puts the burden on the patient, who failed to comply with their plan's requirement. In either case, the first step is to determine whether the second opinion actually exists but was not documented on the claim — which is a fixable administrative issue — or whether it genuinely was never obtained.

Common Causes

How to Resolve

Determine whether a second surgical opinion was obtained, locate the documentation, and submit it with the claim or appeal. If no second opinion exists, explore retroactive options or write off the denial.

1. Verify patient responsibility Confirm that the plan's second opinion requirement applies to the specific procedure and that the patient was responsible for obtaining it.
2. Check if second opinion exists Before billing the patient, verify whether a second opinion was obtained but not submitted with the claim. If found, help the patient file a member-level appeal.
3. Communicate and collect If the second opinion was genuinely not obtained, explain the denial to the patient, provide a clear statement of the amount owed, and offer payment plan options.

How to Prevent PR-61

• Inform patients during the surgical consultation if their plan requires a second opinion, and assist with scheduling.
• Provide patients with a list of approved second opinion providers from their insurance plan.
• Document in the chart that the second opinion requirement was communicated and the referral was made.

General Prevention

• Inform patients during the surgical consultation that their plan requires a second opinion and assist with scheduling.
• Document in the patient's chart that the second opinion requirement was communicated and the referral was made.

Also Filed As

The same CARC 61 may appear with different Group Codes:

Related Denial Codes