PR-204 denial code
Service not covered under the patient's plan, patient responsibility
How to fix it
Bill the patient, provided a valid advance notice was issued before service.
How to prevent it
Issue advance beneficiary notices before delivering likely non-covered services. Without one, this balance is often not collectible.
In practice
A patient receives a service and the remittance returns PR-204 — not covered under the patient's current benefit plan. The PR prefix means the balance is patient responsibility rather than a provider write-off.
Before transferring it, the first check is whether the service is genuinely excluded or whether the wrong plan was billed. Patients frequently hold more than one coverage, and a service excluded under one plan may be covered under another.
Where the exclusion is real, the balance is billable — but a patient who was not told beforehand receives an unexpected bill, which is the most common source of collection disputes and the reason benefit verification matters more than eligibility verification alone.
What sits behind it
PR-204 turns on the distinction between eligibility and benefits, which are commonly conflated. Confirming a patient has active coverage says nothing about whether this particular service is covered under their specific plan.
Plan-level exclusions are the cause here: cosmetic procedures, some dental and vision services, experimental treatments, and services outside the plan's defined benefit set. The patient is covered; the service is not.
Because the balance is patient responsibility, the practice's exposure is a collection problem rather than a write-off. Setting expectation before the service — a documented conversation, an estimate, a signed acknowledgement — converts a disputed bill into an anticipated one, and is far cheaper than pursuing the balance afterwards.
Related codes
Terms used here — Patient Responsibility · Eligibility Verification · Out-of-Network
How we handle it — Eligibility Verification · Patient Collections · Patient Support
Primary sources
The rules behind PR-204, at the bodies that publish them.
- Medicare Benefit Policy Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — What Medicare covers and under what conditions, as distinct from how a claim is processed. The starting point for any coverage or medical necessity question.
- Advance Beneficiary Notice of Noncoverage (ABN) (opens in a new tab)
Centers for Medicare & Medicaid Services — The form and the rules for issuing it. Whether a non-covered service can be billed to the patient usually turns on whether a valid ABN was obtained beforehand.
Every denial code with a guide
Authorization
Bundling
Contractual
Coverage
Data quality
Documentation
Eligibility
Liability and workers comp
Patient responsibility
- PR-204Not Covered by the Plan
- PR-1Deductible Amount
- PR-2Coinsurance Amount
- PR-3Copayment Amount
Provider eligibility
Timely filing
Looking for a different code? Search all 190 CARC and RARC codes
Questions about PR-204
Yes. The PR prefix designates patient responsibility, so the balance transfers rather than being written off. Confirm first that the correct plan was billed — patients often hold more than one coverage, and a service excluded under one may be covered under another.
Both indicate a non-covered service, but the prefix determines who bears the cost. PR-204 makes it patient responsibility. CO-96 makes it a contractual obligation the provider absorbs. The prefix, not the description, decides whether a bill can be sent.
Verify benefits for the specific service rather than only confirming active coverage. Eligibility tells you the patient is insured; benefits tell you whether this service is covered under their plan. Communicating the expected cost before the service converts a disputed bill into an anticipated one.
An ABN is a Medicare instrument. For commercial plans, the equivalent is a documented financial responsibility acknowledgement signed before the service. Either way the point is the same — the patient has to know before, not after.
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