PR-31 denial code
The payer cannot match the patient to a member. The ID, name, or date of birth on the claim doesn't line up with anyone on their rolls — so before arguing about coverage, there is no patient to argue about.
PR — Patient Responsibility. The amount is the patient's to pay: deductible, coinsurance, or copay. These are not denials, and they are collectible.
Why you got it
- 1A digit off in the member ID, a misspelled name, a transposed date of birth. Clerical causes dominate this denial.
- 2The patient handed over an old card after switching plans, and the claim went to last year's payer.
- 3A newborn being billed under their own name before the plan has actually added them to the policy.
- 4The payer migrated or merged member IDs and the one on file with you no longer exists.
How do I fix a PR-31 denial?
- Re-verify with the physical card and a fresh eligibility check. Correct the identifier and resubmit — this is a correction, not an appeal.
- If the plan changed, find the right payer and submit there, minding their timely filing limit, which has been running since the date of service.
- For newborns, get the enrollment completed (the parents may need to act) and resubmit once the child exists in the payer's system.
How to stop the next one
Scan the card and run eligibility at every visit, not just the first one. Coverage changes in January and at every job change, and the front desk is the only place this denial can actually be prevented.
Our diagnosis scrubber will not catch this one. PR-31 is driven by procedure codes, modifiers, or eligibility rather than by the diagnosis set — and procedure-side checking needs CPT codes, which aren’t included yet. We would rather tell you that than sell you a tool that quietly misses your most common denial.
If denials like this are a volume problem rather than a one-off, the denial management page explains how the paid workspace catches the coding causes on every claim, and the free ICD-10-CM lookup shows the coding notes behind any diagnosis code on the remittance.