PR 35 denial code

Claim adjustment reason code 35. Often reported as PR 35.

Lifetime benefit maximum reached

Unofficial reference. This is our own plain-English explanation, not the official code text. Payer rules differ. Verify with the payer and the official X12 code list. AlphaPrefix is not affiliated with X12, CMS or any payer. Data last updated Nov 11, 2026.

What 35 means

The patient has already used up the plan's lifetime maximum for this benefit, so the payer stopped paying for it.

Some plans cap how much they will pay over the life of the policy, for a specific benefit or overall. The payer is saying that cap has been reached.

This is most often seen on benefits that still carry lifetime limits, such as certain therapy, fertility or orthodontic benefits. It is usually reported with PR.

Group codes seen with 35

On a remittance, 35 comes after a group code. These are the ones it is most often reported with:

• PR 35 (Patient Responsibility): The amount is assigned to the patient. Deductibles, coinsurance and copays are the everyday examples. Whether you can collect it still depends on your contract and the patient's plan.

The payer chooses the group code for each adjustment, so the same reason code can appear with another group code on your remittance. Read the two together. More about group codes.

Common causes

• The patient used the full lifetime allowance for this benefit in earlier claims.
• The service was counted against a benefit category with a lifetime cap.
• Claims from other providers used up the maximum before this service.

What to do next

1. Ask the payer for a benefit history showing how the lifetime maximum was used.
2. Check whether the service was put in the right benefit category.
3. Bill any secondary coverage before treating the balance as the patient's.
4. Tell the patient early when a lifetime cap is close, so future services can be planned.

Related codes

• 119 (reason code) Benefit maximum reached
• 149 (reason code) Lifetime benefit maximum reached