PR-26 / PR-27: Service before coverage began, or after it ended

What PR-26 / PR-27 means

Twin codes for the two edges of a policy: 26 means the date of service came before the plan’s effective date, 27 means it came after termination.

What it usually means in a chiropractic office

These cluster around January, when plans change, and around job changes. A patient hands over the new card in March for a plan effective February 1, and January’s visits billed to the new plan bounce with PR-26 while the old plan should have gotten them.

How to work it

1. Pin down the effective and termination dates of both the old and new plans.
2. Rebill each date of service to the plan that was actually active that day.
3. If no plan covered the date, the balance is patient responsibility.

What this looks like in practice

A plan year changes January first. The office bills January visits to the new plan the patient mentioned, but the new plan’s effective date is February first, producing PR-26 denials. The old plan was active through January and would have paid, and still will if its filing window has not closed. The clock, not the coding, is the enemy.

How to stop it from happening again

• ✓Record effective and termination dates whenever eligibility returns them
• ✓Bill each date of service to the plan active on that day, splitting months when coverage changed mid stream
• ✓Move fast on boundary denials; the correct payer’s filing window has been running the whole time

General information for billing teams, not legal or payer specific advice. CARC definitions belong to X12; payer policies vary and control. Verify against the payer contract before acting on any individual claim.