PR Mismatch

What is PR Mismatch?

A PR Mismatch occurs when there is a remaining balance on a claim that hasn’t been properly accounted for after adjudication. In other words, the system is unable to categorize the balance—it has not been adjusted off, nor has it been assigned as the patient’s responsibility.

How can I prevent a PR Mismatch?

While there's no guaranteed way to prevent claims from ending up in PR Mismatch, the best approach is to ensure all charges are fully accounted for during remittance posting. This includes correctly applying:

• Insurance payments

• Adjustments

• Patient responsibility (PR) amounts

• Write-offs

Example:
A claim returns from the payer with a total charge of $174. The applied adjustments total $17, which updates the charge amount to $157. An insurance payment of $129 is posted, leaving a remaining balance of $28. If this amount isn’t assigned as either a write-off, adjustment, or recognized as a denial code, or patient responsibility, it becomes a PR Mismatch.

 

What Should I Do If a Claim Ends Up in PR Mismatch?

If a claim ends up in PR Mismatch, you have three common options:

1. Write off the balance

2. Bill the patient for the remaining amount

3. Resubmit to Insurance to collect remaining amount

There is no “correct” option—it depends on your practice’s policies and the specific situation.

To bill the patient:

• Select the claim by checking the box next to it (you can select multiple).

• Click the drop down of ‘Bulk Bill To Patients’ > 'Selected Claims'.

To write off the claim:

• Click ‘Other Actions’ > ‘Write-Off Claims’.

To resubmit to insurance:

• Click into the claim > 'Actions' > 'Submit' > 'Mark As Ready to Submit'. This will move the claim back to the 'Ready to Submit' bucket where you can then resubmit the claim to the payer. 
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• Please note that some payers may want resubmissions with the resubmission code and original reference number. It is always best practice to consult with the payer to avoid any denials/rejections.