835 Denial Combination
PR-26
Patient Responsibility · Service-Line Level Adjustment
EligibilityWhat This Combination Means
The patient received services before their insurance coverage became effective. The payer has determined that the patient is financially responsible for the full charges because the date of service falls outside the active coverage period.
Financial Responsibility
patient responsibility
The patient owes the full amount because services were rendered before their insurance coverage began or after it ended.
N/A
Appeal Success
Immediate (transfer to patient balance)
Avg. Resolution
Easy
Difficulty
No
Appealable
Step-by-Step Resolution
Steps tailored specifically to this PR-26 combination — not generic advice.
- 1
Verify the service date against the patient's insurance effective date in the eligibility response or member ID card
Confirm whether services truly occurred before coverage started or after it ended
- 2
If dates confirm pre-coverage service, transfer the balance to patient responsibility in your practice management system
This is a valid patient obligation under their benefit plan terms
- 3
Generate patient statement and contact patient to explain that services occurred before insurance coverage was active
Discuss payment arrangements or alternative coverage options that may have been active at the time of service
Specialty Context
How PR-26 typically presents across different practice types.
Dental
Common in orthodontics when treatment spans coverage changes, or when patients schedule preventive visits before new plan year begins; verify if prior carrier covered the date of service
Medical
Frequently seen with new employees scheduling appointments before employer coverage effective date, or with marketplace plans when services occur before plan start date; confirm no gap coverage existed
Behavioral Health
May occur when patients begin therapy during open enrollment but before new plan activates, or during transitions between Medicaid and commercial coverage; check for retroactive eligibility
Individual Code References
View the standalone definition for each code in this combination.
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