PR-204 denial code
The service isn't covered under the patient's current benefit plan, and the PR group code assigns the amount to the patient.
“This service/equipment/drug is not covered under the patient's current benefit plan”
Start 02/28/2007 · X12 adjustment reason code list
What it usually means in behavioral health
Before billing a patient for a PR-204, check the verification of benefits. If intake was told the service was covered, the call reference and notes are your evidence for reprocessing.
Exclusions deserve a second look in behavioral health. A plan that covers an intermediate level of care for medical conditions while excluding the comparable level for mental health or substance use can raise a federal parity question.
Common causes
- Plan excludes the service or level of care
- Service billed to the wrong plan or product for the member
- Benefit changed at plan renewal after the last verification
- Out-of-network benefits don't exist on the member's plan
Correct and resubmit, or appeal?
If the verification record shows the service was covered, ask for reprocessing with the call reference, and appeal if refused. If the exclusion looks like a parity problem, appeal and ask for the plan's comparative analysis. Otherwise it's patient responsibility, subject to any financial agreement and your estimate rules.
What to do
Pull the verification of benefits for the date of service.
Confirm the member's plan and product were billed correctly.
Appeal with the verification record, or on parity grounds where the exclusion warrants it.
Only then bill the patient, consistent with your financial agreement and estimate obligations.
Often seen with
- N130
Got a PR-204 on your desk?
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