PR-31 Denial Code : Causes, Solutions, and Prevention Tips

What is Denial Code PR-31?

The claim has been rejected because the payer cannot identify the patient as a covered member.

This typically happens when patient details, such as name or ID, differ from the records on file with the insurance provider, preventing coverage verification and causing the claim to be denied.

PR-31 denials are significant in medical billing as they interrupt the reimbursement process, often stemming from incorrect or incomplete insurance data. Ensuring patient details are accurate during intake can prevent this issue and facilitate smoother claims processing.

Example of a Claim Denied with PR-31

For instance, if a patient’s ID number or name was entered incorrectly, the insurance provider would be unable to match the data, resulting in a PR-31 denial.

Why Claims are Denied Under PR-31

Denial Code PR-31 is commonly issued due to mismatches or errors in patient information, which prevents the insurance provider from verifying coverage. Here are some common causes:

• Incorrect Patient ID or Policy Number: A mistyped or incorrect ID number can prevent the insurer from locating the patient’s policy details, leading to a denial.

• Mismatched Personal Information: If the patient’s name, date of birth, or other demographic details differ from the insurer’s records, the claim may be denied under PR-31.

• Expired or Inactive Coverage: Claims may be denied if the patient’s insurance policy has expired or been deactivated prior to the date of service, indicating the patient is no longer covered.

• Unlisted Dependent Information: For claims involving dependents, failure to have the dependent correctly listed under the primary policyholder can also lead to PR-31 denials.

Addressing these issues promptly through verification of patient information can help reduce PR-31 denials and streamline claims processing.

How to Resolve Denial Code PR-31

Here’s a step-by-step guide to address PR-31 denial effectively:

Step 1: Review the Denial Notice
Examine the details in the denial notice to understand the specific reason for the denial, such as incorrect patient information or policy status.

Step 2: Verify Patient Information
Double-check the patient’s personal information (name, date of birth, ID number) with what was submitted in the claim to ensure there are no discrepancies.

Step 3: Confirm Insurance Coverage Status
Contact the insurance provider to confirm that the patient’s coverage was active at the time of service. Verify policy details if there’s any indication of an expired or inactive policy.

Step 4: Resubmit Accurate Information
Correct any errors identified, such as patient details or policy numbers. Resubmit the claim with the updated and verified information, ensuring it aligns with the insurer’s records.

Step 5: Communicate with the Patient
If needed, inform the patient of any issues with their insurance coverage, such as expired policies or dependent registration, to prevent future denials.

Step 6: Track the Appeal Process
Once resubmitted, monitor the status of the claim and follow up with the payer if necessary to confirm that the corrected claim is processed.

By following these steps, clinics can efficiently resolve PR-31 denials, minimize delays, and maintain smoother claims management processes.

How SPRY Helps Prevent PR-31 Denials

SPRY's automation ensures that every step of the claims process is accurate and compliant, significantly reducing the likelihood of PR-31 denials. 

Real-Time Insurance Verification: SPRY simplifies eligibility verification with one-click insurance checks, ensuring patient information is accurate and up-to-date before treatment. With support for a range of payers, including on- and off-exchange providers, Medicare, and workers’ compensation, SPRY helps avoid denials from incorrect or inactive coverage details.

Integrated Billing and Claim Management: SPRY's integrated billing system consolidates verified insurance details into the claim process, reducing manual data entry and the risk of typos. Automated scrubbing and payer alerts ensure claims meet insurer requirements, further minimizing rejections.

Error Detection and Compliance: With SPRY's proactive error-flagging, front desk and billing teams can identify missing or incorrect information in patient records before claims submission. This real-time review avoids unnecessary rejections, supports payer compliance standards, and enables smoother revenue cycle management.

By integrating these solutions, SPRY minimizes common causes of PR-31 denials, improving claim accuracy and reducing administrative burden. Schedule a demo to learn more!

FAQs

1. What is Denial Code PR-31?

Denial Code PR-31 indicates that the payer could not identify the patient as insured based on the provided information. It usually results from mismatched insurance details or an inability to verify coverage.

2. Why was my claim denied with PR-31?
Common reasons include incorrect insurance details, such as an outdated policy number or misspelled names, preventing proper identification.

3. Can I appeal a PR-31 denial?
Yes, you can appeal. Make sure to submit corrected information, such as updated insurance details, and provide necessary documentation to verify the patient’s coverage.

‍4. How can I prevent PR-31 denials?
Using automated verification tools, like SPRY, can help confirm insurance details before submitting claims, ensuring accurate patient identification and reducing the risk of PR-31 denials.