PR-242 denial code
The services weren't provided by a network or primary-care provider, so the plan is paying less or nothing and assigning the difference to the patient. Before anyone bills the patient, one question matters most: are you actually out of network, or do the payer's records just say so?
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 rendering provider genuinely isn't in this plan's network — being in-network with the payer's other products doesn't count.
- 2The patient's HMO requires care through their PCP, and this wasn't.
- 3The provider's roster entry is wrong or lapsed — a credentialing or re-enrollment gap making an in-network provider look OON.
- 4The claim's NPI or tax ID doesn't match the contracted entity, so the match fails on paperwork.
How do I fix a PR-242 denial?
- Verify your own participation status for this specific plan first. If you are contracted, dispute with your contract and roster evidence — this happens more than payers like to admit, especially after mergers and re-credentialing cycles.
- Check whether federal or state surprise-billing protections apply — emergency care and out-of-network providers at in-network facilities generally can't be balance-billed beyond in-network cost sharing.
- If you are genuinely out-of-network and no protection applies, the patient's OON benefits govern; bill accordingly and tell them why.
Writing the appeal?
Our free generator drafts a PR-242 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
Verify network participation per plan — not per payer — at scheduling, and keep your credentialing and payer rosters current. A lapsed re-attestation shows up in the world as a wave of these. The CO-242 variant means your contract eats the difference instead.
Our diagnosis scrubber will not catch this one. PR-242 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.