PR-27: Services after coverage ended, patient owes

The payer is telling you the member did not have active coverage on the dates billed, so the plan will not pay. From their view, the service happened after the insurance policy ended or before it started, so the member is financially responsible. Mechanically, the eligibility edit compares the service dates on the claim to the plan's start and end dates on file. Anything outside that window denies with PR-27, and the full denied amount moves to patient responsibility unless another plan is primary.

In behavioral health, PR-27 often hits long stays where coverage ends mid-episode and nobody catches it. Example: PHP billed on a weekly span, but the patient's commercial plan ended on day three and the employer changed carriers; the last days deny PR-27 as patient responsibility. You also see it with residential SUD or detox when a payer carves out behavioral health to a separate administrator and the center keeps billing the medical plan after a termination. For OTP or MAT clinics billing monthly per diem or weekly H codes, recurring claims can suddenly deny with PR-27 when Medicaid or an MCO closes the case or the member loses eligibility. If your team keeps rebilling the same payer without fixing eligibility, you waste weeks, collect nothing from insurance, and end up chasing patients for high per-diem balances they did not expect.

• Check the payer's eligibility and benefit record for exact coverage start and end dates that apply to behavioral health.
• Verify that the dates of service on the UB-04 or 1500 match what was actually provided and are not spanning beyond the active coverage period.
• If the patient had other active coverage for those dates, update coordination of benefits in your system and bill the correct primary plan instead.
• If coverage truly ended before the billed dates, split the claim: submit only the covered days to the payer and move the non-covered days to patient responsibility with clear documentation.
• If you believe the payer's termination date is wrong, obtain proof of coverage from the patient or employer and file an eligibility/termination appeal, not just a corrected claim.
• Once the payer position is final, update your patient statements and financial counseling notes so the patient balance from PR-27 is handled consistently with your charity, payment plan, or self-pay policies.

• Run real-time eligibility for all new behavioral admissions and again at regular intervals for long PHP, residential, and OTP episodes.
• Train front desk and utilization teams to recheck eligibility at each authorization renewal or concurrent review touch point.
• Configure your practice management system to flag upcoming coverage end dates during scheduling so staff can address plan changes before services occur.
• For Medicaid and MCO populations with frequent churn, build a monthly report of high-length-of-stay patients and re-verify coverage before billing new per-diem spans.