PR 227 denial code

What PR-227 means

PR-227 means the payer asked the patient (or the insured or responsible party) for information and did not get it, or got something incomplete, so the claim stopped. The payer sends these requests directly to the member: a coordination-of-benefits questionnaire, an accident detail form, a dependent status confirmation. When the member ignores the letter, every claim in the queue denies with 227, and a remark code on the remittance describes what was requested.

Group code PR parks the balance with the patient, which is fair. The patient controls the fix. But treat the patient statement as the lever, not the endgame. These claims usually pay in full once the patient returns the questionnaire, so the goal is getting that form completed, not collecting the allowed amount from the patient.

Contrast with CO-16, where the claim is missing information the provider must supply. With 227, your claim was fine; the payer’s file on the member is not.

Common causes

1. Coordination-of-benefits questionnaire not returned: payers periodically ask members to confirm whether other coverage exists, and unanswered COB requests are the single biggest source of 227 denials. Related territory to CO-22.
2. Accident or injury questionnaires: the payer suspects auto, workers’ compensation, or liability involvement and wants details before paying.
3. Dependent eligibility verification: student status, disabled dependent status, or divorce-related coverage questions.
4. Medicare Secondary Payer development: CMS’s Benefits Coordination & Recovery Center asking the beneficiary to clarify other coverage.
5. Subrogation forms after a third-party injury claim.
6. The patient returned the form, but incomplete, or it crossed in the mail with the denial.

How to fix and resubmit

1. Read the remark code to identify exactly what the payer requested and from whom.
2. Call the payer if the remark is vague. Confirm what was sent to the patient, when, and what is still outstanding. Get a reference number.
3. Contact the patient. Explain plainly: the plan will not pay any claims until this form goes back, and the balance is theirs until it does. Offer to three-way call the payer’s member services with the patient. It resolves COB questionnaires in one call.
4. Once the patient responds, ask the payer whether it will reprocess automatically or needs a resubmission. Many payers reprocess all pended claims once the member file updates; confirm rather than assume, and diary the claim for 30 days.
5. If the patient will not cooperate after documented attempts, transfer the balance to the patient per the PR group code and your financial policy. Keep records of your outreach.
6. Appeals do not fit here. There is no adverse determination to argue, just a stalled file. Exception: if the patient can prove they returned the form before the denial, ask the payer to reprocess with that proof.

How to prevent it

• Ask about other coverage at every registration and update the COB answers in your system; submitting accurate COB data on claims reduces how often payers develop the member directly.
• Screen for accident and injury mechanisms at intake, and collect liability and workers’ compensation details when they apply.
• For Medicare patients, complete an MSP questionnaire on the schedule your MAC expects so secondary-payer development does not start with the payer.
• When a 227 hits one claim, sweep the patient’s other pending claims; the same unanswered request will take them all down, and one phone call fixes the batch.