How do I fix or resolve code PR-204?

Review the patient's benefit plan documents or summary plan description (SPD) to confirm the service is genuinely excluded and that the payer correctly assigned responsibility to the patient. Verify whether the patient signed an Advance Beneficiary Notice (ABN) or financial responsibility form before the service was rendered; if so, bill the patient for the non-covered amount. If the plan has a formulary exception or coverage exception process, submit a request with supporting clinical documentation and a letter of medical necessity from the treating provider. If no ABN was obtained, the patient may not be billable — file an appeal with the payer or write off the balance as a provider adjustment depending on the plan's provisions. If the patient has secondary insurance that may cover the excluded service, submit the claim to the secondary payer with the primary EOB showing the non-covered determination.

PR-204Denial CodePatient Responsibility

Code PR-204

Problem Description

This service/equipment/drug is not covered under the patient's current benefit plan.

Root Cause

The service, equipment, or drug is not covered under the patient's current benefit plan, and the payer has assigned financial responsibility to the patient. This is a plan-level exclusion where the service is not a covered benefit under the patient's current plan tier or formulary. Unlike CO-204 (where the provider typically writes off the contractual adjustment), PR-204 means the patient is liable for the charge. Common examples include cosmetic procedures, fertility treatments, off-formulary drugs, or elective services excluded from the plan. The provider must have obtained an ABN or financial responsibility form to bill the patient.

Resolution Steps

1Review the patient's benefit plan documents or summary plan description (SPD) to confirm the service is genuinely excluded and that the payer correctly assigned responsibility to the patient.
2Verify whether the patient signed an Advance Beneficiary Notice (ABN) or financial responsibility form before the service was rendered; if so, bill the patient for the non-covered amount.
3If the plan has a formulary exception or coverage exception process, submit a request with supporting clinical documentation and a letter of medical necessity from the treating provider.
4If no ABN was obtained, the patient may not be billable — file an appeal with the payer or write off the balance as a provider adjustment depending on the plan's provisions.
5If the patient has secondary insurance that may cover the excluded service, submit the claim to the secondary payer with the primary EOB showing the non-covered determination.

EHR Documentation Note

Claim denied PR-204 — service not covered under plan, patient responsibility; verified ABN status, billed patient if ABN signed, or filed appeal if notification was not provided.

Preventative Action

Verify benefit coverage for non-standard services during pre-visit eligibility checks and obtain signed ABNs before rendering services likely to be excluded from the patient's plan.

Related Codes in Patient Responsibility

PR-3

Co-payment Amount

PR-96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

PI-100

Payment made to patient/insured/responsible party.

PI-101

Predetermination: anticipated payment upon completion of services or claim adjudication.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.