PR P3 denial code
Claim adjustment reason code P3. Often reported as PR P3.
Workers' comp settled: patient responsible
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 .
What P3 means
The workers' compensation case was settled, and the patient is responsible, often through a Medicare set aside arrangement.
It appears on workers' compensation claims only. It tells you the case has been closed by settlement, and that care after the settlement is now the patient's responsibility, frequently paid from a Medicare set aside or similar arrangement.
P3 is only used with group code PR. Check the settlement terms and the funding arrangement before deciding how to bill the patient.
Group codes seen with P3
On a remittance, P3 comes after a group code. These are the ones it is most often reported with:
- PR P3 (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 workers' compensation claim settled before the date of service.
- The settlement put future medical costs on the patient through a set aside account.
- The provider billed the carrier after the case closed.
What to do next
- Confirm the settlement date and terms with the carrier or the patient's attorney.
- Ask the patient whether a set aside account or administrator pays for related care.
- Bill the responsible party in line with the settlement and your patient financial policy.
Related codes
- P2 (reason code) Not a work related injury or illness
- P4 (reason code) Workers' comp claim found non-compensable
Source
Official wording: X12 Claim Adjustment Reason Codes list. The explanation on this page is our own plain-English wording, not the X12 text.
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