Email: info@webillhealth.com | Call: +1 (425) 818 9351
Business hours: Monday to Friday, 8am to 9pm EST
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.
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
Group code PR
Patient Responsibility. X12 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
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
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
In the official words
Non-covered charge(s)
You must submit a claim to Medicare that results in a payment decision the patient can appeal.
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 X12 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
How to clear a PR 96 denial
- Read the remark code and the plan benefit documents to confirm the service is not covered.
- 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.
- If a valid ABN is on file, bill the patient the balance and keep the ABN with the account.
- 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.
- 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
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.
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.