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.