PR-204 means the service, equipment, or drug is not covered under the patient's current benefit plan, and the patient is responsible. Before you bill the patient, confirm the right plan was billed and the service was coded correctly. Then bill clearly, because a patient who did not expect the bill is the hardest balance to collect.
1. What PR-204 means
- PR (Patient Responsibility): the patient can be billed, subject to your contract and any notice rules.
- 204: this service, equipment, or drug is not covered under the patient's current benefit plan.
The key word is "current". PR-204 often appears after a plan change, when a service the old plan covered is excluded from the new one.
2. PR-204 vs CO-96 vs PR-96
| Code | Meaning | Who pays |
|---|---|---|
| PR-204 | Not covered under the patient's current benefit plan | Patient |
| PR-96 | Non-covered charge | Patient |
| CO-96 | Non-covered charge | Provider |
See our CO-96 and PR-96 guide for how non-covered charges work.
3. What to do with a PR-204
- Confirm the plan. Was this the patient's plan on the date of service? If they had other coverage, see CO-22.
- Check the coding. A covered service billed with the wrong code can look excluded. If so, send a corrected claim.
- Check for secondary coverage that might cover what the primary excludes.
- Appeal if you believe the service is covered, or ask about a medical exception where the plan offers one, with supporting documentation.
- Bill the patient with a clear statement that explains the plan exclusion, and offer payment options.
4. Payer-by-payer notes on PR-204
| Payer | What to know |
|---|---|
| Medicare | Original Medicare rarely uses 204. Non-covered services usually come back as 96 with a remark code (see CO-96 and PR-96). Expect PR-204 mainly from Medicare Advantage and commercial plans. |
| Medicare Advantage | Check the plan's Evidence of Coverage, including any supplemental benefits. If the plan should cover the service, ask for reconsideration (the MA first-level appeal) within the deadline on the notice. |
| Medicaid | Billing a Medicaid patient for a non-covered service is restricted. Most states require the patient's written agreement before the service. Without it, you usually cannot collect. |
| Commercial and Marketplace plans | Benefits differ by plan and by state. Services such as infertility, bariatric surgery, and some therapies are often optional riders. Verify with a service-type eligibility check (270/271) or a call before the visit, and collect a signed waiver if the patient chooses to proceed. |
5. How to prevent surprises
- Check benefits for the specific service before the visit, not just active coverage. See our eligibility verification guide.
- Re-verify after plan changes, especially in January and after open enrollment.
- Get a signed financial agreement before services a plan is known to exclude, where your contract allows it.
Related: PR-1, CO-45, and the full CARC and RARC codes list.
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