PR-200 denial code
The expenses fall inside a lapse in coverage — the policy existed, but premiums weren't current when the service happened, so the plan is holding the patient responsible. Unlike a termination, a lapse can sometimes be cured after the fact.
PR — Patient Responsibility. The amount is the patient's to pay: deductible, coinsurance, or copay. These are not denials, and they are collectible.
Why you got it
- 1Premiums went unpaid and the coverage lapsed before the date of service.
- 2The patient is inside a premium grace period — marketplace plans with subsidies have a long one, and claims from its later stretch pend or deny until the premiums are paid.
- 3A retroactive termination for non-payment reached back past the visit.
How do I fix a PR-200 denial?
- Have the patient contact the plan about reinstatement. If they pay the back premiums inside the grace period, lapsed claims are typically reprocessed — this denial can literally undo itself.
- Verify the actual lapse dates against the date of service; payers get these wrong at the boundaries.
- If the lapse stands, the balance is the patient's. Bill promptly and plainly — the longer it sits, the more it surprises them.
How to stop the next one
Eligibility checked close to the date of service, especially for marketplace coverage early in the year. A patient in month two of a grace period shows 'active' on a shallow check and becomes this denial on a deeper one.
Our diagnosis scrubber will not catch this one. PR-200 is driven by procedure codes, modifiers, or eligibility rather than by the diagnosis set — and procedure-side checking needs CPT codes, which aren’t included yet. We would rather tell you that than sell you a tool that quietly misses your most common denial.
If denials like this are a volume problem rather than a one-off, the denial management page explains how the paid workspace catches the coding causes on every claim, and the free ICD-10-CM lookup shows the coding notes behind any diagnosis code on the remittance.