PR-122 Denial Code Explained

PR-122 is a medical billing denial code that indicates a benefit limitation or coverage restriction has been applied and the remaining balance is the patient's responsibility. This denial commonly occurs when insurance plan limits have been reached or a service falls outside covered benefits.

What Does PR-122 Mean?

The PR-119 denial code means the patient's insurance benefits have reached the maximum amount allowed under the plan.

This denial is often related to annual benefit limits, service-specific maximums, or coverage restrictions.

Common Reasons for PR-122

• Benefit limitation reached

• Coverage restriction applies

• Service exceeds plan allowance

• Maximum benefit exhausted

• Frequency limitation exceeded

• Plan-specific coverage rules

How To Fix PR-122

Review the patient's explanation of benefits and verify the benefit limitation responsible for the adjustment. Confirm the patient's coverage details and determine whether the balance is appropriately assigned to patient responsibility.

If the denial appears incorrect, contact the payer and request a review of the patient's benefits and coverage limitations.

Frequently Asked Questions

What is a benefit limitation denial?

A benefit limitation denial occurs when a patient's insurance plan restricts coverage based on annual limits, visit limits, frequency limits, or other plan rules.

What is the difference between PR-119 and PR-122?

PR-119 typically indicates a benefit maximum has been reached, while PR-122 is generally associated with a broader benefit limitation or coverage restriction.

Can prior authorization prevent a PR-122 denial?

Not always. Even when a service receives prior authorization, benefit limitations and coverage restrictions may still apply depending on the patient's plan.

Does PR-122 mean the service was medically unnecessary?

No. PR-122 is generally related to benefit limitations or coverage restrictions rather than medical necessity determinations.

How can providers verify benefit limitations before treatment?

Providers should review eligibility and benefits information, verify coverage limits with the payer, and confirm any visit, frequency, or annual benefit restrictions before services are rendered.

Related Denial Codes

You may also encounter:

• PR-1 — Deductible amount

• PR-2 — Coinsurance amount

• PR-3 — Copayment amount

• PR-119 — Benefit maximum reached

Quick Summary

PR-122 indicates a benefit limitation or coverage restriction was applied and the remaining balance is assigned to patient responsibility. Most denials are caused by coverage limits, exhausted benefits, or plan-specific restrictions.