PR-B1: Non-Covered Visits
The non-covered visit is the patient's responsibility. Bill the patient for the full amount of the non-covered service.
What Does PR-B1 Mean?
PR-B1 assigns the non-covered visit directly to the patient's financial responsibility. The payer is saying the service is not covered under the plan, and the patient is responsible for the full charge. This pairing is appropriate when the patient received a service excluded from their plan benefits and should have been informed of the coverage limitation. The provider can and should bill the patient for the amount.
When CARC B1 appears on a remittance, the payer is telling you that the specific visit or service billed is not a covered benefit under the patient's insurance plan. This is a broad coverage denial that can apply to many service types — office visits, therapy sessions, specialty consultations, or any encounter that falls outside the plan's benefit structure.
The group code paired with B1 is critical for determining your next action. CO-B1 means the non-covered visit is a contractual obligation where the provider absorbs the cost — typically seen when the provider is in-network and the contract limits what can be billed for non-covered services. PR-B1 means the non-covered visit is the patient's financial responsibility — the patient knew or should have known the service was not covered, and the provider can bill the patient for the full amount.
B1 denials can stem from straightforward plan exclusions (the plan simply does not cover that type of visit) or from more nuanced issues like exceeded benefit limits, missing prior authorization, or incorrect coding that made a covered service appear non-covered. Before accepting the denial, it is worth verifying that the correct procedure code was used and that the service does not fall under a covered benefit category. A simple code correction can sometimes convert a B1 denial into a paid claim.
Common Causes
| Cause | Frequency |
|---|---|
| Service excluded from plan benefits The visit type is explicitly excluded from the patient's insurance plan, and the patient is responsible for the full cost because the service was never a covered benefit | Most Common |
| Benefit maximum reached The patient has used all covered visits for this service type in the current benefit period, and any additional visits are the patient's financial responsibility | Most Common |
| Patient chose out-of-network provider The patient knowingly received services from an out-of-network provider where the plan provides no coverage, making the patient responsible for the full charge | Common |
How to Resolve
Verify whether the service is genuinely non-covered or if a coding or authorization issue caused the denial, then take action based on the group code.
- Confirm non-coverage Verify that the service is genuinely not covered under the patient's plan. If it should be covered, help the patient file a member-level appeal with their insurer.
- Transfer to patient responsibility Move the charge from insurance A/R to patient A/R in your billing system. Generate a patient statement that clearly explains the service was not covered by their insurance plan.
- Contact the patient Reach out to explain the non-coverage and the amount owed. Offer payment options or payment plans for larger balances.
- Follow standard patient collections Enter the balance into your standard patient collections workflow — statement cadence, follow-up calls, and escalation procedures.
This adjustment is correct per the patient's benefit plan. The amount is the patient's financial responsibility.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-B1:
| RARC | Description |
|---|---|
| N130 | Alert: You may need to review plan documents or guidelines to determine coverage restrictions for this service. |
| N386 | This decision was based on the submitted/requested information. |
How to Prevent PR-B1
- Verify insurance coverage for the specific service type before the appointment and inform the patient if the service is not covered
- Collect an Advance Beneficiary Notice (ABN) or similar waiver before rendering services that may not be covered, so the patient is aware of their financial responsibility
- Track benefit visit limits and notify patients when they are approaching or have reached their maximum covered visits
- Provide upfront cost estimates for non-covered services so patients can make informed decisions
General Prevention
- Verify insurance coverage and check remaining benefit limits for the specific visit type before scheduling appointments
- Obtain prior authorization when required by the payer for specific visit types or service categories
- Inform patients in advance if a planned visit may not be covered by their insurance, including an estimate of out-of-pocket costs
- Ensure the correct visit type and procedure codes are used on claims to avoid misclassification as non-covered
- Track visit frequency against benefit limits to proactively notify patients when they are approaching or have reached their maximum covered visits
- Stay current with payer policy changes regarding covered visit types and benefit limitations
Also Filed As
The same CARC B1 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/b1
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.