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.
Usually lost. Recoverable only with unusual evidence. Triage by dollar value.
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.
Read the RARC. If it points at a documentation gap rather than the benefit itself, it is appealable.
The documentation, not the argument.
A signed ABN, which moves the balance to patient responsibility.
Whatever the RARC actually asks for, if it points at a documentation gap.
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.
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.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound