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Note on April 30, 2024: The Athelas Blocked PR system has now been transitioned over to the PR Write-Off Rules. Going forward all CARCs you wish to eliminate PR for should be implemented as rules via the steps listed below. If you have any questions, please contact your account representative for assistance.

At a Glance

The Athelas PR Write-Off Rules give you increased flexibility in deciding what is Valid vs. what is Invalid PR for your practice. Select a combination of CARCs, Payers, CPTs, DOS and many other factors to make sure PR is automatically written off.

How do PR Write-Off Rules Work?

Each night when Athelas runs its processes to analyze remittances and add new PR to patient balances, new PR will automatically be compared against your PR Write-Off rules.

Any PR that matches a rule will be momentarily added to the patients balance, then immediately written off. This differs from the previous system where PR never reached patient accounts at all, which was less flexible and less accurate from a bookkeeping perspective.

You can also create a rule to prevent automatic write-offs of PR that would normally occur via the Athelas Global rules, which target the most common problematic forms of PR.

How to Create a Rule

From the Patient Responsibility page, click the ‘Actions’ menu and choose PR Settings.

Next, click on the PR Write Off Rules tab, then Add Rule.

In the popup, give your rule a Name and set its Priority. Rules with priority set to higher values will override those with lower values. For example, rules with priority 2 override those with priority 1.

For an example, let’s imagine you want a rule that will write off post-visit PR when the CPT code is 27365 and the primary payer is not Aetna. In the Actions block, you’ll choose what outcome you want your rule to achieve. In this example, you want it to write off post-visit PR.

Now, you’ll set the conditions under which this rule will engage. We’ll choose condition type All in this example, as we want PR to meet both criteria, and not just one.

Set the first variable to CPT code, the operator to Contains All, and the value to 27365.

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Note: This CPT code is from our test system. Your organization’s CPT codes will automatically populate this menu.

Click ‘Add Statement.’ Now, set the new variable to Primary Payer, the operator to Shares No Elements With, and the Value to Aetna. Click Save.

And your rule is ready! On a nightly basis rules will be applied during the same process where PR is analyzed and added to patient balances.

If you ever need to pause, edit, or update one of your rules at a later date, you can do so from the list of PR Write Off Rules on this page.

What PR will be written off by default?

By default the Athelas Global PR Rule writes off most PR CARCs that are not Co-Pay, Coinsurance, or Deductible.

Some of the broad reasons we get these CARCs are:

Other Responsible Party: There is another payer that should be footing the cost, despite the designation of ‘PR’ as the group code.

Implied Denial: These claims have been denied and should be resubmitted.

Clerical Error: These are CARCs that are generally not PR, but have come in under a PR group code anyhow.

If you want to re-enable any of the below CARCs for PR, talk to your Athelas account manager and they can help you set up an Exclusion.

Here’s the full list of CARCs:

CARC	Description
PR-16	Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation.
PR-19	This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
PR-22	This care may be covered by another payer per coordination of benefits.
PR-26	Expenses incurred prior to coverage.
PR-27	Expenses incurred after coverage terminated.
PR-31	Patient cannot be identified as our insured.
PR-45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
PR-50	These are non-covered services because this is not deemed a 'medical necessity' by the payer.
PR-58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
PR-95	Plan procedures not followed.
PR-96	Non-covered charge(s).
PR-97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
PR-109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
PR-166	These services were submitted after this payers responsibility for processing claims under this plan ended.
PR-172	Payment is adjusted when performed/billed by a provider of this specialty.
PR-197	Precertification/authorization/notification/pre-treatment absent.
PR-200	Expenses incurred during lapse in coverage
PR-204	This service/equipment/drug is not covered under the patient's current benefit plan.
PR-227	Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete.
PR-242	Services not provided by network/primary care providers
PR-279	Services not provided by Preferred network providers.
PR-A1	Claim/Service denied.
PR-B11	The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
PR-B14	Only one visit or consultation per physician per day is covered.
PR-B16	'New Patient' qualifications were not met

Further Assistance

📢 Please contact your account manager if you would like some hands-on assistance.

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