How do I fix or resolve code PI-101?

Review the predetermination letter or payer portal notification to confirm the anticipated payment amount, the covered services, and any patient responsibility estimates. Verify that the predetermination covers the services being rendered and that the CPT/HCPCS codes match the predetermination approval. Inform the patient of the anticipated payer payment and their estimated out-of-pocket responsibility before rendering the service; obtain a financial responsibility acknowledgment. After the service is completed, submit the final claim with the predetermination reference number in the appropriate 837 loop to ensure the payer matches the claim to the approved predetermination. If the payer's final adjudication differs from the predetermination, file an appeal referencing the predetermination approval and requesting payment consistent with the pre-service determination.

PI-101Adjustment CodePatient Responsibility

Code PI-101

Problem Description

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

Root Cause

The payer has issued a predetermination indicating an anticipated payment upon completion of services or claim adjudication. This is not a denial — it is an informational adjustment indicating that the payer has reviewed the proposed service and determined it will likely be covered, subject to final claim submission and adjudication. The predetermination is a pre-service review that provides the patient and provider with an estimate of what the payer will pay. The patient may be responsible for any remaining balance after the payer's anticipated payment. This is commonly used for high-cost procedures, surgeries, and dental services where pre-service cost estimates are required.

Resolution Steps

1Review the predetermination letter or payer portal notification to confirm the anticipated payment amount, the covered services, and any patient responsibility estimates.
2Verify that the predetermination covers the services being rendered and that the CPT/HCPCS codes match the predetermination approval.
3Inform the patient of the anticipated payer payment and their estimated out-of-pocket responsibility before rendering the service; obtain a financial responsibility acknowledgment.
4After the service is completed, submit the final claim with the predetermination reference number in the appropriate 837 loop to ensure the payer matches the claim to the approved predetermination.
5If the payer's final adjudication differs from the predetermination, file an appeal referencing the predetermination approval and requesting payment consistent with the pre-service determination.

EHR Documentation Note

Claim adjusted PI-101 — predetermination anticipated payment; verified predetermination approval, informed patient of estimated responsibility, and submitted claim with predetermination reference.

Preventative Action

Obtain predeterminations for all high-cost or elective procedures and ensure the predetermination reference number is included on the final claim to prevent payment discrepancies.

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-100

Payment made to patient/insured/responsible party.

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.