PR 96: Non-Covered Charge
Not a covered charge under this plan.
Read the RARC. If it points at a documentation gap rather than the benefit itself, it is appealable.
See a finished review first
- No patient data
- No BAA
- No charge
- No pitch
What PR 96 means
PR: Patient responsibility. This one goes on the patient statement.
So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
The same code, a different prefix. 96 also arrives as CO 96. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says CO 96, read that page instead.
Is It Worth Appealing?
Usually lost. Recoverable only with unusual evidence. Triage by dollar value.
Why It Fires
In the order we see it.
A benefit exclusion in the patient's plan.
A missing or invalid ABN on a Medicare claim.
The RARC beside it often names the real reason, which may be documentation rather than the benefit.
How to Appeal PR 96, Step by Step
Read the RARC. If it points at a documentation gap rather than the benefit itself, it is appealable.
- 1Step 1: Read the remark code. Find the remark code printed next to PR 96 on the 835 or EOB. It says what the payer wants back. The usual ones are N130, N115, N30.
- 2Step 2: Find the cause. Match the denial to one of the 3 causes in Why It Fires above, and fix that one.
- 3Step 3: Take the first action. Read the RARC. If it points at a documentation gap rather than the benefit itself, it is appealable.
- 4Step 4: Attach the documentation. A signed ABN, which moves the balance to patient responsibility. Whatever the RARC actually asks for, if it points at a documentation gap.
- 5Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window. See what an appeal letter must contain and the filing limits by payer.
The common mistake. Do not treat this as final until you have read the RARC. It frequently hides an appealable reason behind a non-covered label.
Free: the Denial Code Appeal Playbook. 53 codes on one sheet: appeal, fix and resubmit, or let it go, and what to attach. Get the playbook
PR 96 description
Not a covered charge under this plan.
Not a covered charge under this plan. So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
The Remark Code Beside It
The adjustment code says the claim was reduced. The remark code printed next to it says why, and it is the one that tells you what to send back.
| Remark | What it means |
|---|---|
| N130 | The member's plan restricts this service, and the payer has pointed you at the benefit document instead of naming the restriction. |
| N115 | The decision came from a Local Coverage Determination, the regional Medicare policy that says when this service is covered. |
| N30 | The patient was not eligible for this particular service on that date. That is narrower than not being covered at all, and the difference matters. |
| N59 | The payer has pointed you at the provider manual rather than naming the rule it applied. |
| N180 | The payer says what you billed does not qualify for the billing category you put it under. |
Related Codes
Your Questions Answered
What does PR 96 mean?
Not a covered charge under this plan. Patient responsibility. This one goes on the patient statement.
Can you appeal PR 96?
Usually lost. Read the RARC. If it points at a documentation gap rather than the benefit itself, it is appealable.
Why does PR 96 happen?
A benefit exclusion in the patient's plan. A missing or invalid ABN on a Medicare claim. The RARC beside it often names the real reason, which may be documentation rather than the benefit.
What documentation wins a PR 96 appeal?
A signed ABN, which moves the balance to patient responsibility. Whatever the RARC actually asks for, if it points at a documentation gap.
How do I appeal a PR 96 denial?
Step 1: Read the remark code. Find the remark code printed next to PR 96 on the 835 or EOB. It says what the payer wants back. Step 2: Find the cause. Match the denial to one cause: A benefit exclusion in the patient's plan. A missing or invalid ABN on a Medicare claim. The RARC beside it often names the real reason, which may be documentation rather than the benefit. Step 3: Take the first action. Read the RARC. If it points at a documentation gap rather than the benefit itself, it is appealable. Step 4: Attach the documentation. A signed ABN, which moves the balance to patient responsibility. Whatever the RARC actually asks for, if it points at a documentation gap. Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window.
Most searched: CO 97 · CO 96 · OA 23 · PR 204 · CO 109 · CO 197 · CO 45 · CO 50
How Much of This Is Sitting in Your Write-Off Pile?
No patient data. No BAA. No charge.
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