How do I fix or resolve code PI-100?

Verify the payer's payment to the patient by checking the ERA/EOB for the payment amount and the payee designation (patient/insured). Contact the patient to inform them that the insurance payment was sent directly to them and request that they remit the payment to the provider's office. If the patient has already received the check, provide payment instructions and set a deadline for remittance; document the communication in the patient account. If the patient has not received the check or disputes the payment, contact the payer to verify the payment date, check number, and mailing address, and request a reissue if the check was lost. If the patient refuses to remit the payment, pursue collections per the provider's financial policy or consider whether small claims court is appropriate for the outstanding balance.

PI-100Adjustment CodePatient Responsibility

Code PI-100

Problem Description

Payment made to patient/insured/responsible party.

Root Cause

The payer made the payment directly to the patient or insured rather than to the provider. This occurs when the provider is out-of-network, the patient assigned benefits to themselves, or the plan requires payment to the member for certain service types. The patient is now responsible for remitting the payment to the provider. This is a patient responsibility adjustment (PI group) — the payer has fulfilled its obligation by paying the patient, and the provider must collect from the patient. This is common with out-of-network providers, certain behavioral health plans, and plans with member-directed payment provisions.

Resolution Steps

1Verify the payer's payment to the patient by checking the ERA/EOB for the payment amount and the payee designation (patient/insured).
2Contact the patient to inform them that the insurance payment was sent directly to them and request that they remit the payment to the provider's office.
3If the patient has already received the check, provide payment instructions and set a deadline for remittance; document the communication in the patient account.
4If the patient has not received the check or disputes the payment, contact the payer to verify the payment date, check number, and mailing address, and request a reissue if the check was lost.
5If the patient refuses to remit the payment, pursue collections per the provider's financial policy or consider whether small claims court is appropriate for the outstanding balance.

EHR Documentation Note

Claim adjusted PI-100 — payment made to patient; contacted patient to remit insurance payment to provider, documented communication, and set remittance deadline.

Preventative Action

Verify assignment of benefits status at each visit and inform out-of-network patients that payment may be sent directly to them, requiring them to forward the payment to the provider.

Related Codes in Patient Responsibility

PR-3

Co-payment Amount

PR-96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

PR-204

This service/equipment/drug is not covered under the patient's current benefit plan.

PI-101

Predetermination: anticipated payment upon completion of services or claim adjudication.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.