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Denial code
PR 204 denial code, plan coverage confirmed
PR 204 means the plan does not cover the service. Confirm the benefit, then bill the patient or appeal.
A PR 204 denial says the service, equipment or drug is not covered under the patient's current benefit plan, and the amount is assigned to the patient. Before you bill the patient, confirm the plan, the effective dates and whether a notice was required.
What CARC 204 says
This service/equipment/drug is not covered under the patient's current benefit plan. X12 reason codes
Group code PR
Patient Responsibility. X12 group codes
ABN and Medicare Advantage
CMS says not to use an ABN for Medicare Advantage or Medicare drug plan items and services. CMS, ABN tutorial
Services that are never covered
CMS recommends a voluntary ABN or a similar notice as a courtesy for care that is not a benefit or is never covered. CMS, ABN tutorial
In the official words
This service/equipment/drug is not covered under the patient's current benefit plan
The patient (or their representative) must sign the notice to indicate they got it and understand its contents.
Check the benefit plan first
PR 204 depends on the patient's plan, not on the coding alone. X12 words it as not covered under the patient's current benefit plan, so the plan on the claim may have changed, ended or never included the benefit. Confirm what plan was active on the date of service and what it covers. X12 reason codes
For Original Medicare, an ABN is the notice used to move liability to the patient. CMS says not to use an ABN for Medicare Advantage or Medicare drug plan items and services, so the plan type decides which notice rules apply. For care that is never covered, CMS recommends a voluntary notice as a courtesy. CMS, ABN tutorial
How to clear a PR 204 denial
- Verify the plan and its effective dates for the date of service.
- If the claim went to the wrong plan, correct the payer and send the claim again.
- If the plan is right and the benefit is excluded, read the plan documents for an exception or an appeal route.
- Check what notice the patient received before the visit, and keep a copy with the account. For Medicare, CMS says the patient or representative must sign the ABN.
- Bill the patient only after the plan and notice checks above support it, and only for the amount the remit assigns. Explain the denial before the statement goes out.
If the patient has both Medicare and Medicaid, the limits on charging the patient are set out in the PR 96 guide. Check them before any statement goes out.
Stop PR 204 before it starts
Plan coverage is easiest to settle before the visit. Eligibility, plan type and the benefit for the service can be checked and shared with the patient in advance.
WeBill Health maintains internal payer rule libraries organized by specialty and by carrier, built and updated by people who work claims in your specialty every day. Every claim receives Human Expert Review against them before it goes out.
Denial Defense 2.0
Root cause denial work that closes the documentation gaps behind repeat denials before they disrupt your revenue cycle.
clean claim rate
A/R reduction within 90 days
payer rulesets in our rule libraries
Find the denials that keep coming back
The Revenue Defense Audit is a free, forensic review of your claims and A/R by the team that would work your account. It maps your denial patterns by payer and code, with the root cause behind each one.
Check my Revenue Defense Score for the denial exposure in your specialty.