CommonPatient Responsibility (PR)Prior Authorization

PR-204: Service not covered/authorized under patient's plan

The service or procedure is not covered or not authorized under the patient's current benefit plan. The full charge is the patient's responsibility.

Common Causes

  • Service requires prior authorization that was not obtained
  • Plan specifically excludes this service type
  • Benefit limits have been exhausted for the plan year
  • Service is covered on other plans but not this specific plan type

How to Resolve PR-204

  1. 1Verify the specific denial reason with the payer
  2. 2If authorization-related, attempt retroactive authorization
  3. 3If benefit exclusion, bill the patient
  4. 4Help the patient file their own appeal with the payer if they believe it should be covered

How to Prevent PR-204 Denials

  • Verify both coverage and authorization requirements before every service
  • Use automated tools to check PA requirements across all payers
  • Provide patients with cost estimates before scheduled services

Related Denial Codes

PR-96Common

Non-covered charge (patient responsibility)

CO-15Very Common

Authorization required but not obtained

CO-197Very Common

Precertification/authorization/notification absent

Stop Denials Before They Happen

Greenlight automatically checks prior authorization requirements and submits PA requests before the service is rendered -- eliminating authorization denials entirely.

See How It Works