PR-97: Bundled Service — Not Paid Separately

What Does PR-97 Mean?

PR-97 means the payer has determined the billed service is bundled into another procedure, and the patient's benefit plan makes the patient financially responsible for the denied amount. This is uncommon for CARC 97 — most bundling denials are CO. PR-97 typically occurs when the patient's plan design treats the bundled component as a non-covered service rather than a contractual write-off, often seen with out-of-network arrangements or limited benefit plans. Always verify the PR assignment is correct before billing the patient.

CARC 97 fires when a payer's adjudication system identifies that a billed service is considered a component of another procedure already being paid on the same claim or within a global surgical period. The payer applies bundling logic — most commonly the CMS National Correct Coding Initiative (NCCI) Column 1/Column 2 edits — to determine that the two codes cannot be billed separately. The Column 2 code (the less comprehensive service) is denied, and only the Column 1 code (the more comprehensive service) is reimbursed.

This denial is not always an error. Many CARC 97 denials are correct: the billed service genuinely is an inherent part of the primary procedure. Specimen collection during an office visit, simple wound closure during a surgical procedure, and post-operative E/M visits within the global period are all legitimately bundled. The key question is whether the denied service was truly distinct and independently performed, or whether it was a component of the paid procedure.

The financial outcome depends on the Group Code. CO-97 is far more common and represents a contractual write-off — the provider absorbs the denied amount and cannot bill the patient. PR-97 is less frequent and shifts the bundled amount to the patient, typically when the patient's benefit plan design treats the denied component as a non-covered service. Always verify the Group Code assignment is correct before taking action, particularly for PR-97 where incorrect assignment could result in improper patient billing.

Common Causes

How to Resolve

Determine whether the bundling is correct by checking the NCCI modifier indicator, then either write off, resubmit with modifiers, or appeal based on the findings.

1. Verify the PR assignment is correct Review the EOB/ERA and cross-reference the PR-97 denial against the payer contract and the patient's benefit plan. Many bundling denials should be CO (provider write-off), not PR. If the assignment appears wrong, contact the payer to request reclassification before billing the patient.
2. Check if the service can be unbundled Look up the NCCI modifier indicator for the code pair. If the indicator is 1 and the service was legitimately distinct, correct and resubmit the claim with the appropriate modifier and documentation before billing the patient.
3. Review the patient's benefit plan Confirm that the patient's specific plan treats bundled services as patient responsibility. Some plans route bundling denials to PR only for out-of-network or non-covered situations.
4. Contact the payer if assignment is incorrect If the PR assignment does not align with contractual terms — particularly if the provider is in-network and bundling should be a contractual adjustment — contact the payer directly to have the Group Code corrected to CO.
5. Bill the patient if PR is valid If the PR-97 assignment is confirmed correct and the bundling determination is accurate, bill the patient for the denied amount. Provide a clear explanation of why the service was not covered separately under their plan.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-97:

How to Prevent PR-97

• Verify the patient's benefit plan coverage details before rendering services to identify procedures that may be bundled under their specific plan
• Review payer contracts to understand when bundling denials should be CO versus PR, and proactively challenge incorrect PR assignments
• Inform patients about their plan's bundling policies during scheduling when procedures commonly trigger bundling denials
• Confirm with the payer that the denied amount is appropriately assigned as patient responsibility before sending a patient statement

General Prevention

• Verify the patient's benefit plan coverage details before rendering services to identify which procedures may be bundled under their specific plan
• Review payer contracts to understand when bundling denials should be CO vs PR, and challenge incorrect PR assignments proactively
• Educate patients about their plan's bundling policies when scheduling procedures that commonly trigger bundling denials
• Confirm with the payer whether the denied amount is appropriately assigned as patient responsibility before sending a patient bill

Also Filed As

The same CARC 97 may appear with different Group Codes:

Related Denial Codes