# PR 96 Denial Code: What the Patient Owes and the ABN

> PR 96 means the charge is not covered and the amount is patient responsibility. See when an Advance Beneficiary Notice matters and how to bill the balance.

Source: https://webillhealth.com/pr-96-denial-code/  
Publisher: WeBill Health  
Last updated: November 4, 2026

Denial code

## PR 96 denial code, patient balance explained

PR 96 puts a not covered charge on the patient. An ABN decides whether Medicare lets you bill it.

[Request a Revenue Defense Audit](https://webillhealth.com/revenue-defense-audit/request/)

A PR 96 denial means the payer treats the charge as not covered and assigns the amount to the patient. Before you send a statement, check the remark code and whether the right notice was given. For Medicare, that notice is the Advance Beneficiary Notice of Noncoverage.

* What CARC 96 says
Non-covered charge(s). [X12 reason codes](https://x12.org/codes/claim-adjustment-reason-codes)
* Group code PR
Patient Responsibility. [X12 group codes](https://x12.org/codes/claim-adjustment-group-codes)
* When an ABN is required
Providers must issue an ABN to transfer financial liability to the patient when they expect Medicare to deny a service it generally covers. [CMS, ABN tutorial](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)
* Patient appeal rights
When the patient chooses to receive the service, you must submit a claim to Medicare that results in a payment decision the patient can appeal. [CMS, ABN tutorial](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)
* Patients with Medicare and Medicaid
Once Medicare and Medicaid adjudicate the claim, you may charge the patient only in these circumstances, such as QMB coverage without full Medicaid coverage. [CMS, ABN tutorial](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)

## In the official words

> Non-covered charge(s)

[X12](https://x12.org/codes/claim-adjustment-reason-codes)

> You must submit a claim to Medicare that results in a payment decision the patient can appeal.

[Centers for Medicare & Medicaid Services](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)

## What the patient owes and why

X12 names the PR group Patient Responsibility, and reason 96 says the charge is not covered. A remark code such as N130 points you to the plan documents: Consult plan benefit documents/guidelines for information about restrictions for this service. What the patient actually owes depends on the payer’s rules and, for Medicare, on the notice that was given. [X12 group codes](https://x12.org/codes/claim-adjustment-group-codes) [X12 remark codes](https://x12.org/codes/remittance-advice-remark-codes)

For Original Medicare, an ABN is how a provider moves liability to the patient when a service that Medicare generally covers is expected to be denied. The patient must choose one of three options on the form. [CMS, ABN tutorial](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)

## How to clear a PR 96 denial

1. Read the remark code and the plan benefit documents to confirm the service is not covered.
2. For Medicare, find the signed ABN for the date of service and check that it names the service. CMS says an ABN is valid when it is the most recent OMB approved version, the entire form is complete and the patient understands it.
3. If a valid ABN is on file, bill the patient the balance and keep the ABN with the account.
4. If an ABN was required and not given, CMS says it may hold the provider liable, so do not assume the patient owes the amount. Review the denial and appeal where the service should have been covered.
5. Tell the patient what the denial means before the statement arrives, and log the cause.

For a patient with both Medicare and Medicaid, CMS says that once both have adjudicated the claim you may charge the patient only in listed circumstances, such as QMB coverage without full Medicaid coverage. Check those before any statement goes out. [CMS, ABN tutorial](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)

## Stop PR 96 before it starts

Patient responsibility denials are easiest to handle at scheduling. If a service is likely to be not covered, the conversation and the notice come before the visit, not after the remit.

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.

## Sources

* [X12 reason codes](https://x12.org/codes/claim-adjustment-reason-codes)
* [X12 group codes](https://x12.org/codes/claim-adjustment-group-codes)
* [CMS, ABN tutorial](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html)
* [x12.org, remittance advice remark codes](https://x12.org/codes/remittance-advice-remark-codes)

## Denial Defense 2.0

Root cause denial work that closes the documentation gaps behind repeat denials before they disrupt your revenue cycle.

**98%**

clean claim rate

**40%**

A/R reduction within 90 days

**500+**

payer rulesets in our rule libraries

[See Denial Defense 2.0](https://webillhealth.com/denial-defense-2-0/)

## Related denial codes

These codes often appear beside PR 96 or clear the same way.

* [CO 22](https://webillhealth.com/co-22-denial-code/)
* [CO 45](https://webillhealth.com/co-45-denial-code/)
* [CO 96](https://webillhealth.com/co-96-denial-code/)

See every code on [Denial Codes Explained: What Each Means and How to Clear It](https://webillhealth.com/denial-codes/). When the same denial keeps returning, read the [Denial Root Cause Playbook](https://webillhealth.com/denial-root-cause-playbook/).

Reviewed by [Tyler Nguyen](https://webillhealth.com/tyler-nguyen/), Denial Defense Manager, on November 4, 2026. Facts verified November 1, 2026.

## 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](https://webillhealth.com/revenue-defense-score/?specialty=chiropractic) for the denial exposure in your specialty.

[Request a Revenue Defense Audit](https://webillhealth.com/revenue-defense-audit/request/)

WeBill Health is a specialty focused revenue cycle management partner for independent practices. Request a Revenue Defense Audit at https://webillhealth.com/form/