PR-201PR group · Patient responsibility

PR-201 denial code: patient liable under a set-aside arrangement

PR-201 points at money that already exists for exactly this purpose, held somewhere other than the health plan.

PR-201 assigns liability to the patient under a set-aside arrangement — funds allocated in a workers' compensation or liability settlement to pay for future related medical care.

What PR-201 means

A set-aside is money reserved from a settlement, administered either by the beneficiary or professionally, and it must be exhausted on related care before the health plan or Medicare pays. So the denial is directional rather than final: it says this claim belongs to the set-aside account. The practical work is identifying the administrator and billing them, which the patient can usually facilitate.

Why PR-201 fires

  • A workers' compensation set-aside covers care related to the injury.
  • A liability settlement allocated funds for future medical care.
  • The set-aside has not been reported as exhausted.
  • The care is related to the settled injury by the payer's assessment.

Is PR-201 worth appealing?

Rarely an appeal — usually a fix

The direction is usually right. Identify the set-aside administrator and bill there; if the funds are exhausted, that has to be established and reported before the health plan takes over.

PR-201 — frequently asked

What is a set-aside?
Money reserved from a workers' compensation or liability settlement to pay future medical care related to the injury. It must be spent on that care before other coverage pays.
What if the funds are exhausted?
Then the health plan or Medicare becomes responsible, but exhaustion has to be documented and reported. Until it is, claims keep routing to the set-aside.

Related guides

CO-19 · Coordination of benefitsCO-20 · Coordination of benefitsCO-21 · Coordination of benefits

Sources

Reason-code meanings are paraphrased from the X12 Claim Adjustment Reason Code list for plain-language reference; they are not reproduced verbatim. This is general information, not legal, coding, or medical advice — always confirm against the payer's remittance and policy.

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