PR-96 denial code
Non-covered charge, and the patient owes it. Same reason as CO-96 — the service is not a benefit — but the PR prefix moves the money: instead of a write-off, the payer is saying this amount is legitimately billable to the patient.
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 is excluded under the patient's plan, and the payer holds the patient responsible for exclusions.
- 2For Medicare: a valid ABN was on file, so the statutorily or medically non-covered service shifts to the patient as intended.
- 3A coding error made a covered service look like an excluded one — worth ruling out before anyone gets a bill.
How do I fix a PR-96 denial?
- Confirm the exclusion is real before billing the patient. Pull the benefit language or call — a wrong code can manufacture a 'non-covered' out of a covered service.
- Check your notice obligations. Medicare wants a valid ABN signed before the service; many commercial contracts require advance notice before you can collect for non-covered care. If the notice wasn't given, the PR prefix does not automatically make the balance collectible.
- If the exclusion was misapplied, appeal with the benefit language and the corrected coding. If it is genuine and your notices are in order, bill the patient — this one is theirs.
Writing the appeal?
Our free generator drafts a PR-96 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 benefits for the service category before rendering it, and get the ABN or waiver signed when coverage is doubtful. The moment to establish who pays is before the service, not on the remit.
Our diagnosis scrubber will not catch this one. PR-96 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.