Denial Code PR 50 - Medical Necessity Tips & Fixes
Code 50 indicates that the payer has determined the service is not a 'medical necessity', and therefore, it will not be covered. The payer's decision is based on their medical necessity criteria, which is detailed in the 835 Healthcare Policy Identification Segment if provided.
Who Pays: Group Code Liability
Read the group code carefully on code 50 — it decides everything. CO-50 means the provider absorbs the denial: for Medicare this is the classic no-ABN scenario, and billing the patient for a service denied as not medically necessary is prohibited. PR-50 means the patient accepted financial responsibility in advance — typically through a signed ABN or a commercial plan’s equivalent notice — and can be billed. Never move a CO-50 balance to the patient; if the service was genuinely necessary, the remedy is an appeal with clinical documentation, not a patient statement.
Why Claims Get Code 50
- The service doesn't meet the payer's medical necessity criteria.
- Required documentation to support medical necessity was not submitted.
- Patient's diagnosis does not align with the payer's guidelines for the service.
- The service is considered experimental or investigational by the payer.
- The payer has specific coverage policies that were not met.
How to Fix & Resubmit
- Review the 835 Healthcare Policy Identification Segment for specific payer criteria.
- Verify if the service meets the payer's medical necessity guidelines.
- Collect and submit any missing documentation that supports medical necessity.
- Contact the payer to clarify their medical necessity criteria if unclear.
- If justified, resubmit the claim with additional information or documentation.
Corrected Claim or Appeal?
For code 50, if the service truly meets medical necessity, submit a corrected claim with supporting documentation. If the payer's criteria are still not met, an appeal with detailed supporting information may be required.
Preventing Future 50 Denials
- Ensure all services have supporting documentation for medical necessity before submission.
- Stay updated on each payer's specific medical necessity guidelines.
- Train staff to accurately link diagnosis codes that support medical necessity.
- Regularly review payer policies for changes in coverage criteria.