CommonPatient Responsibility (PR)Patient Responsibility

PR-96: Non-covered charge (patient responsibility)

The service is not covered under the patient's plan and the full charge is the patient's responsibility. Unlike CO-96 (which is a contractual write-off), PR-96 means the patient can be billed for the full amount.

Common Causes

  • Service is excluded from the patient's plan benefits
  • Patient selected a plan that does not cover this service type
  • Service is considered cosmetic, elective, or non-essential by the plan
  • Benefit maximum has been reached for this service category

How to Resolve PR-96

  1. 1Bill the patient for the full amount of the non-covered service
  2. 2Provide an itemized statement with the denial reason
  3. 3If the patient disputes, help them appeal directly with their insurance
  4. 4Offer payment plan options for large balances

How to Prevent PR-96 Denials

  • Verify specific service coverage before rendering non-emergent services
  • Have patients sign an ABN (Advance Beneficiary Notice) or financial waiver for potentially non-covered services
  • Inform patients of their estimated responsibility before the visit

Related Denial Codes

CO-96Common

Non-covered charge(s)

PR-204Common

Service not covered/authorized under patient's plan

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