PR-204 denial code
The service is not covered under the patient's current benefit plan, and the balance is the patient's. Close cousin of PR-96, with one trap worth knowing: 'not covered under THIS plan' sometimes means covered under a different one the patient also has.
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
- 1The service category simply isn't in the plan: hearing aids, routine vision, cosmetic procedures, adult dental under a medical plan.
- 2The benefit is carved out to another entity — behavioral health, dental, vision and pharmacy are routinely administered by a separate company, and the medical payer denies its half truthfully.
- 3The plan changed at renewal, and last year's covered service is this year's exclusion.
How do I fix a PR-204 denial?
- Check for a carve-out before accepting the denial at face value. If behavioral health is administered separately, the claim isn't non-covered — it went to the wrong company. Find the right one and file there, watching their timely filing clock.
- Verify the benefit with the current plan year, not your notes from last year.
- If it is genuinely excluded and your notice obligations are met, bill the patient. If the payer misread its own plan, appeal with the benefit language.
Writing the appeal?
Our free generator drafts a PR-204 appeal letter that opens with the argument above — it runs entirely in your browser, so the claim details never leave your screen. No signup.
Generate the appeal letterHow to stop the next one
Benefit verification that names the specific service category, and a note of which benefits are carved out to whom. The CO-204 variant means the same thing with the write-off assigned to you instead — usually a network-contract consequence.
Our diagnosis scrubber will not catch this one. PR-204 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.