Skip to main content

PR-238 Denial Code: Ineligible Coverage Period Reduction

PR-238 means the claim spans both eligible and ineligible periods of coverage, and this adjustment is the reduction for the ineligible period. It is patient responsibility, and X12 allows CARC 238 only with group code PR.

Quick facts

Code
PR-238 (CARC 238)
Status
Active In use since March 1, 2012; last modified July 1, 2013.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • PR (Patient Responsibility): The amount for the days or services outside coverage is the patient's responsibility. X12 restricts CARC 238 to the PR group.
Official description
Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What PR-238 means

CARC 238 says the claim spans eligible and ineligible periods of coverage, and this is the reduction for the ineligible period. The payer processed the claim, paid what fell within coverage, and assigned the rest to the patient.

This happens on claims that cover a span of dates rather than a single visit. Example: an inpatient stay runs from the 28th of one month to the 3rd of the next, and the patient’s coverage ended on the last day of the first month. The payer pays for the covered days and reports the charges for the remaining days as PR-238.

X12 restricts CARC 238 to group code PR, so the reduction is always framed as patient responsibility.

Common causes

  • Coverage terminated partway through a stay or billing period, for example because of a job change or non-payment of premium.
  • Coverage started partway through a period, such as a new enrollment effective mid-month.
  • Plan change at the start of a new plan year during a continuous service period.
  • Monthly rental or episode billing where the billing period crosses the coverage boundary.

How to fix it

  1. Verify the eligibility dates with the payer and compare them to the claim’s from and through dates.
  2. If the payer’s dates are wrong, for example retroactive reinstatement, ask for reprocessing with the corrected eligibility.
  3. Look for other coverage for the ineligible period: a new employer plan, Medicaid, or COBRA continuation.
  4. Bill the other payer for the ineligible portion if one exists, including the primary’s EOB where needed.
  5. If no other coverage applies, bill the patient for the PR-238 amount according to your financial policy.

For eligibility verification practices, see eligibility and COB denials.

How to prevent it

  • Recheck eligibility at the start of each billing period for ongoing services, not just at admission.
  • Ask patients about upcoming coverage changes, such as job changes or plan-year transitions.
  • Flag stays and rentals that cross a month or plan-year boundary for an extra eligibility check.
  • Split billing periods at known coverage changes before submitting.

Remark codes that may appear with PR-238

  • N30 (Patient ineligible for this service.): The patient was ineligible for the service during part of the period.
  • N619 (Coverage terminated for non-payment of premium.): Coverage terminated for non-payment of premium, one common reason for the ineligible period.
  • CO-239 (Claim spans eligible and ineligible periods of coverage.): The claim also spans eligible and ineligible periods, but the payer wants separate claims instead of reducing this one.
  • PR-27 (Expenses incurred after coverage terminated.): The expense was incurred after coverage terminated, for a whole claim or service.
  • PR-26 (Expenses incurred prior to coverage.): The expense was incurred before coverage started.
  • CO-200 (Expenses incurred during lapse in coverage): The expense was incurred during a lapse in coverage.

PR-238 FAQ

What is the difference between PR-238 and CO-239?

Both involve a claim that crosses covered and uncovered dates. With 238, the payer pays the covered part and assigns the uncovered part to the patient. With 239, the payer rejects the claim and asks you to rebill it as separate claims.

Can I bill the patient for PR-238?

Generally yes, since the PR group assigns it to the patient. First confirm the eligibility dates are correct and check for other coverage that might apply to the ineligible period.

What claims usually get PR-238?

Claims with a date range, such as inpatient stays, monthly DME rentals, or home health episodes, where coverage began or ended partway through.

Can PR-238 happen on a single-day claim?

Rarely. It is designed for claims that span a range of dates. On a single date of service, the payer would normally use a coverage-terminated or not-yet-effective code for the whole line instead.