PR-27 Denial Code: Expenses Incurred After Coverage Terminated
PR-27 means expenses were incurred after coverage terminated — the patient's policy had ended before the date of service. With the PR group code the balance is patient responsibility, though it should first be treated as an eligibility check: verify the exact termination date, since stale or retroactive eligibility data is a frequent false trigger before you bill the patient.
- Group
- PR — Patient Responsibility (CO for Medicare)
- Category
- Coverage terminated / eligibility
- Appealable?
- Yes — with proof coverage was active on the DOS
- Typical fix
- Verify termination date; rebill correct payer or bill patient
What does denial code PR-27 mean?
PR-27 tells you the patient\'s coverage had ended before the service was rendered. The official X12 description is "Expenses incurred after coverage terminated." The payer\'s records show the policy terminated before the date of service, so the claim is not covered. With the PR group code the balance is patient responsibility, though Medicare typically issues this as CO-27 because it considers itself primary.
Because eligibility data drifts between scheduling and the visit, PR-27 is best worked as an eligibility check first — a stale or retroactive termination is a common false trigger for a patient who is actually covered.
Why does PR-27 happen?
- Policy genuinely ended — the patient lost coverage before the date of service.
- Retroactive termination — the payer\'s file updated after the fact to a termination date before the visit.
- Wrong or prior payer — the claim went to a plan the patient left, while a new plan is now active.
- Stale COB data — coordination of benefits not refreshed, so the terminated policy was billed.
Mini-example: 99213 ($92) billed for an April 10 visit to a plan that terminated March 31. The payer returns PR-27 and the $92 shifts to patient responsibility. If the patient started a new plan on April 1, redirecting the claim to that payer recovers the $92 instead of billing them.
How do you work a PR-27?
- Run a real-time eligibility check for the exact date of service and capture the termination date.
- If coverage was active, appeal with the eligibility proof — the payer file may have been wrong.
- If the patient moved to a new plan, redirect the claim to the correct payer before the timely filing window closes.
- If coverage truly ended and no other payer applies, bill the patient.
How do you prevent PR-27?
Verify eligibility at scheduling and again at check-in, and re-run it when a patient mentions a job change, retirement, or new plan. Keep coordination-of-benefits data current so the right payer is billed. When an identity or coverage denial is ambiguous, distinguish PR-27 from CO-31 and CO-140 using the denial code lookup so a live-coverage keying error is not mistaken for a true termination.
Frequently asked questions
Only after confirming coverage truly ended before the date of service. PR-27 carries the PR group code, so a correct denial is patient responsibility. But stale or retroactive eligibility data often triggers a false PR-27 for a covered patient. Verify the exact termination date and check for a newer plan before sending a statement.
Eligibility often changes between scheduling and the visit, or the payer's file updated after a retroactive termination. The patient may have switched plans, aged off a policy, or the claim went to a prior carrier. Coordination-of-benefits data can also be stale. Run a fresh eligibility check for the exact service date.
Appeal only with documented proof coverage was active on the date of service — an eligibility verification response, an authorization, or an updated termination date from the payer. If a different payer was actually primary or the patient moved to a new plan, redirect the claim there rather than appealing the terminated policy.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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