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PR-204 Denial Code: Not Covered Under Patient's Plan

PR-204 means the service, equipment, or drug is not covered under the patient's current benefit plan, and the payer has assigned the amount to the patient. Before billing the patient, confirm your contract, any required advance notice, and whether the claim was coded correctly.

Code: PR-204 (CARC 204)
Status: Active In use since February 28, 2007.
Code set: Claim Adjustment Reason Codes (CARC)
Group codes: PR (Patient Responsibility): The most common use. The plan excludes the service and the patient is responsible, subject to your network agreement and any notice requirements.
CO (Contractual Obligation): The payer holds the provider responsible, for example when the contract requires advance notice or a waiver that wasn't obtained. Write it off.
PI (Payer Initiated Reduction): A payer-initiated reduction. Ask the payer whether the patient can be billed, and appeal if the service should have been covered.
Official description: This service/equipment/drug is not covered under the patient's current benefit plan
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified: September 24, 2026 against the official X12 list.

What PR-204 means

CARC 204 reads “This service/equipment/drug is not covered under the patient’s current benefit plan.” The patient has coverage, but the plan doesn’t include this item as a benefit. With group code PR, the payer is telling you the patient is responsible.

This is different from medical necessity (CARC 50), where the service is a covered benefit but wasn’t justified for this patient. With 204, the plan doesn’t cover the service at all, or doesn’t cover it in the circumstances billed. Common examples include cosmetic procedures, some vision and hearing services, certain elective treatments, and drugs not on the plan’s list.

Example: a patient receives a routine hearing exam. Their plan excludes routine hearing care. The claim comes back PR-204, and the practice bills the patient under the financial agreement they signed at check-in.

Common causes

Plan exclusions for the service category (cosmetic, routine vision or hearing, some fertility or weight-loss services, depending on the plan).
Drug not on the formulary or not covered under the medical benefit.
Equipment excluded from the plan’s DME benefit.
Coverage carve-outs, such as behavioral health or pharmacy managed by a different company.
Coding errors that make a covered service look excluded.
Plan changes at the start of a plan year that removed a benefit.

How to fix it

Confirm the exclusion. Check the eligibility response, plan documents, or call the payer about the specific service.
Review coding. If the procedure or diagnosis codes were wrong, submit a corrected claim (resubmission code 7 in box 22) with accurate codes.
Check for carve-outs. If another company administers that benefit (for example behavioral health), send the claim there.
Check notice requirements. Confirm your contract and, for Medicare, whether an ABN or other notice applied and was obtained.
Bill the patient when the exclusion is valid and notice requirements are met, and explain the denial clearly.
Appeal if the plan documents support coverage, or help the patient file a member appeal.

How to prevent it

Verify benefits for the specific service before providing it, not just active coverage. See eligibility and COB denials.
Use written financial agreements for services that are often excluded, signed before the service.
Identify carve-outs at registration so claims go to the right company.
Track PR-204 by payer and service to update your front-desk estimates. ERA Analyzer can break down patient-responsibility denials by service and payer.
Recheck benefits each plan year, since exclusions change.

Specialty notes

Behavioral health practices sometimes see PR-204 when a plan carves out mental health benefits to a separate administrator; the claim then belongs with that administrator. DME suppliers see it for items outside the plan’s equipment benefit.

Remark codes that may appear with PR-204

N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Points to plan documents describing the exclusion or restriction.
N425 (Statutorily excluded service(s).): The service is statutorily excluded, for example under Medicare law.
N115 (This decision was based on a Local Coverage Determination (LCD).): An LCD was applied, which can define coverage limits for the service.
MA01 (Alert: If you do not agree with what we approved for these services, you may appeal our decision.): Medicare appeal-rights alert with the deadline for disagreement.

CO-96 (Non-covered charge(s).): A general non-covered charge denial that requires a remark code to explain it.
CO-50 (These are non-covered services because this is not deemed a 'medical necessity' by the payer.): Not medically necessary. The service is a covered benefit but wasn't justified in this case.
CO-167 (This (these) diagnosis(es) is (are) not covered.): The diagnosis isn't covered, which may be what really makes the service non-covered.
CO-202 (Non-covered personal comfort or convenience services.): A specific type of exclusion: personal comfort or convenience services.
CO-55 (Procedure/treatment/drug is deemed experimental/investigational by the payer.): The service is considered experimental or investigational.

CARC and RARC Codes: Read Denials From the ERA: Learn how CARC and RARC codes explain payer adjustments and denials, and how practices can turn ERA history into repeatable denial-prevention rules.

PR-204 FAQ

Can I bill the patient for PR-204?

Usually yes, since the PR group code assigns responsibility to the patient. However, your network contract may require that the patient was told in advance and agreed in writing, and Medicare has its own ABN rules for some situations. Check both before sending a bill.

Should I appeal PR-204?

Appeal if you believe the service is covered under the plan documents, was coded incorrectly, or falls under an exception. If it's truly excluded, an appeal is unlikely to change the result.

What's the difference between PR-204 and CO-96?

Both say the charge isn't covered. PR-204 specifically points to the patient's benefit plan and assigns responsibility to the patient. CARC 96 is a general non-covered code; when it comes with the CO group, the provider absorbs it.

Can a coding error cause PR-204?

Yes. The wrong procedure or diagnosis code can make a covered service look like an excluded one. Review coding before billing the patient.

Does PR-204 mean the patient has no insurance?

No. The patient has active coverage, but this particular service, item, or drug isn't a benefit of their plan.

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