How do I fix or resolve code PR-96?

Locate the accompanying Remittance Advice Remark Code (RARC) on the ERA/EOB to determine the specific reason the charge is non-covered and assigned to patient responsibility. Verify whether the patient signed an Advance Beneficiary Notice (ABN) or financial responsibility form acknowledging non-coverage before the service was rendered; if so, bill the patient for the full amount. Review the patient's benefit plan documents to confirm the service is genuinely excluded and that the payer correctly assigned responsibility to the patient rather than the provider. If no ABN was obtained and the service was not clearly excluded, file an appeal with the payer arguing that the patient should not be held responsible without proper notification of non-coverage. If the patient disputes the charge, provide a detailed explanation of benefits and the payer's non-covered determination; offer a payment plan or financial assistance if appropriate.

PR-96Denial CodePatient Responsibility

Code PR-96

Problem Description

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.)

Root Cause

The charge is non-covered and the payer has determined that the patient is responsible for the amount. At least one Remittance Advice Remark Code (RARC) accompanies this CARC to explain why the charge is non-covered under the patient's plan. Unlike CO-96 (where the provider typically writes off the contractual adjustment), PR-96 shifts the financial responsibility to the patient. This occurs when the service is excluded from the plan benefits and the patient was notified (or should have been notified) of non-coverage, or when the patient elected to receive a service they knew was not covered.

Resolution Steps

1Locate the accompanying Remittance Advice Remark Code (RARC) on the ERA/EOB to determine the specific reason the charge is non-covered and assigned to patient responsibility.
2Verify whether the patient signed an Advance Beneficiary Notice (ABN) or financial responsibility form acknowledging non-coverage before the service was rendered; if so, bill the patient for the full amount.
3Review the patient's benefit plan documents to confirm the service is genuinely excluded and that the payer correctly assigned responsibility to the patient rather than the provider.
4If no ABN was obtained and the service was not clearly excluded, file an appeal with the payer arguing that the patient should not be held responsible without proper notification of non-coverage.
5If the patient disputes the charge, provide a detailed explanation of benefits and the payer's non-covered determination; offer a payment plan or financial assistance if appropriate.

EHR Documentation Note

Claim denied PR-96 — non-covered charge, patient responsibility; verified ABN status, billed patient if ABN signed, or filed appeal if patient was not properly notified.

Preventative Action

Obtain signed ABNs for all services likely to be non-covered under the patient's plan, and verify coverage before rendering non-standard services to prevent patient balance disputes.

Related Codes in Patient Responsibility

PR-3

Co-payment Amount

PR-204

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

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.