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Key Takeaways
- PR 31 denial code is sent by insurance payers to inform the provider that the patient in the submitted claim is not part of their database.
- This denial is caused by various reasons, such as incorrect patient information, outdated COB or insurance card, or the claim being sent to the wrong primary payer.
- This denial can affect revenue flow if the provider fails to address the root cause and refile a corrected claim.
- A strong insurance verification system, a proactive approach to data review, and a robust denial management system are key to preventing future PR 31 denials.
- It takes only a few days for payers to process claims after the provider successfully fixes the PR 31 denial code.
At Credex Healthcare, we understand the complications that can arise from denied claims. That is why providers nationwide use our comprehensive billing services. Credex Healthcare is a premier medical billing company that takes pride in its high claim approval rate and near-zero denial rate, ensuring practices and their respective providers receive reimbursements on time.
Of the many issues surrounding medical billing, a PR 31 denial code seems to be a major one. When your practice sees this code in its paper trails, there’s no need to worry. Credex Healthcare has the appropriate, efficient workflow to fix it.
What Does PR 31 Denial Code Mean?
PR 31 denial code implies that an insurance company did not identify the patient. This could also mean that the patient is not found in the payer’s internal database. This can put the wronged patient in an uncomfortable position, as they may claim that they are indeed insured and have an active insurance card. The problem, then, may be on your end, particularly in your database.
The first thing that should be reviewed is the core information: the patient’s full name, date of birth (DOB), gender, and policy ID. Any incorrect information immediately leads to claim rejection.
There are also times when a patient provides an outdated insurance card. Some others accidentally enter their DOB or name incorrectly on their registration forms. Minor errors, such as extra spaces, can trigger a system mismatch. If a payer identifies these errors, they return a PR 31 denial code, which must be addressed by the provider promptly and submitted as a refiled claim.
Common Reasons for PR 31 Denials
PR 31 denials are caused by entry errors, particularly incorrect patient information. When the patient’s declared full name, for instance, and the one in the insurance company’s database do not match, the claim will not go through. The same goes for minor errors, such as a missing middle name or a typo. Another error is the one in the insurance ID digits. Obviously, the error occurs when the digits are entered incorrectly.
Another reason is outdated information. The patient may have changed employment or room plans and forgotten to inform the provider. They may not have updated their insurance card, either. This likewise triggers a denial code and needs updating.
Other denial reasons include incorrectly selecting the payer ID and transmitting claims to the wrong clearinghouse, among others.
How to Fix PR 31 Denials
Fortunately, there is an easy way to reverse a PR 31 correspondence. First, double-check the entire patient profile, especially the patient’s full name, DOB, and insurance ID digits. Cross-review the claim details and the insurance card for alignment and accuracy. In case of errors, address them immediately and resubmit the claim.
If this does not work out, you can coordinate with the insurance company. Verify if the patient is active on the date of service. Inquire about further reasons for denial. The patient may have changed their treatment plans, or the service may be out of coverage. Coordinating with the payer will lead you to an appropriate evaluation for resubmission.
Best Practices to Prevent PR 31 Denials
To prevent PR 31 denials from coming back, be proactive in your workflows. Train your front desk staff to deal with the most common errors in patient information and initiate insurance verification for both new and current patients, including insurance coverage and the insurance card. Practices are also advised to use real-time eligibility checkers to see whether patients are still active.
Another best practice is specifying the data entry format used by the practice and partner insurers. Even minor errors, like entering “John Doe” instead of “John Doe, Jr.” can be automatically denied. Lastly, ensure your billing software transmits claims to the appropriate clearinghouse, and the payment list is correct.
What Happens If You Ignore PR 31 Denials?
Failure to fix errors that trigger a PR 31 denial can be costly. If the denied claim is not refiled within the resubmission window, it could prolong the entire claim submission process. This also means that the insurance company will not process the claim, and worse, the claim will expire.
A single claim expiration translates to thousands of dollars in lost reimbursement. If the same situation occurs across multiple claims, your A/R increases, cash flow will decline, and your revenue performance suffers.
How Long Does It Take to Fix PR 31 Denials?
PR 31 denials can be resolved within a few days if caught early. The timeline, however, depends on how promptly you resolve it, whether you are updating patient information or coordinating with the insurance payer. Once the identified errors are corrected and the claim is submitted promptly, you can receive the reimbursement in no time.
At Credex Healthcare, we have an established workflow for resolving PR 31 denials with a 72-hour guaranteed refiling. Providers do not have to wait weeks for the issues to be resolved.
Why Choose Credex Healthcare for Denial Management
Resolving denials requires time, skill, and established workflows. Only a few billing companies have these qualities. Credex Healthcare, being one of them, specializes in streamlined claims submission and PR 31 denial management. Our staff are trained in eligibility review, payer regulations, claim monitoring and appeals systems. We apply a proactive, prompt approach to preventing denials, whether they have already occurred or will in the future.
We also provide billing and credentialing services to make your practice organized, compliant, and financially sound. We have established ties with commercial and federal payers, as well as managed care plans. Whether you are a solo provider or a member of a multispecialty network, we provide a denial management plan based on your needs and goals.
As long as Credex Healthcare supports your denial management, you are free from lost claims or entry errors. We make billing and claims processing easier and error-free, as many healthcare providers in the United States who trust us can attest.
Conclusion
The PR 31 denial code occurs frequently, and there may be several reasons why. To proactively review your vulnerable claims, ensure your patient information is accurate and aligns with the insurance payer records. With robust claims management and billing support from a premier company like Credex Healthcare, PR 31 denials can no longer be a source of disruption in your revenue cycle.
FAQs
What is the meaning of the PR 31 denial code?
From the payer’s end, this code is described as “the patient cannot be identified as our insured.” It could be because the claim was sent to the wrong payer, or the coordination of benefits (COB) is outdated.
Why get the PR 31 denial?
There are various reasons why practices receive a PR 31 denial. It could be due to billing the wrong insurance as the primary payer, outdated insurance information, or COB.
What can I do to fix the PR 31 denial code?
To resolve this denial, process a correct insurance order for the patient, update the payer’s COB, and submit the claim to the primary payer.
Are PR 31 denials avoidable?
Yes. You can avoid such denial correspondence by verifying insurance on each patient’s visit, reviewing COB status, and using automated eligibility tools.
What happens when the patient is unaware of their primary payer?
Coordinate with insurance companies to verify the patient’s COB status. They may require you to provide the patient’s DOB or employment status.
