What does PR-96 mean?

PR-96 means non-covered charge(s) assigned to patient responsibility. PR is the patient-responsibility group code and 96 means the service isn't a covered benefit under the patient's plan. Always read the accompanying RARC for the specific reason.

Can I bill the patient for a PR-96 denial?

Generally yes, because PR shifts the balance to the patient, but verify it's correctly non-covered first, and follow payer rules. For Medicare you typically need a signed ABN on file to hold the patient liable.

What is the difference between PR-96 and CO-96?

Same reason (non-covered) but different responsibility. PR-96 can be billed to the patient; CO-96 is a contractual obligation you must write off and cannot bill to the patient.

Can you appeal a PR-96 denial?

Yes, if you believe the service should have been covered, for example a coding error, an authorization that was actually on file, or a medical-necessity argument supported by documentation.

PR-96 Denial Code: Non-Covered Charges Explained

PR-96on a remittance means “non-covered charge(s)” assigned to patient responsibility. It’s one of the more consequential codes to get right, because unlike a contractual write-off, PR-96 can usually be billed to the patient, but only if it was applied correctly. Treat every PR-96 as “verify before you bill or write off.”

What PR-96 means

PR is the group code for Patient Responsibility. The balance may be passed to the patient.
96 is the reason code for Non-covered charge(s). The payer says this service isn’t a covered benefit under the patient’s plan.

PR-96 almost never travels alone. The accompanying RARC(remark code, e.g. N130 “consult plan benefit documents,” or a code citing missing information) tells you whyit’s non-covered, and whether you’re looking at a real exclusion or a fixable error.

Why PR-96 happens

The service is genuinely excluded from the patient’s plan.
A benefit maximum or frequency limit has been reached.
The service is considered experimental or not medically necessary.
Coverage had lapsed or eligibility wasn’t active on the date of service.
A coding choice mapped the service to a non-covered code when a covered one applied. In other words, the denial is really a coding error wearing a PR-96 label.

Bill the patient, appeal, or write off?

Because PR-96 shifts the balance to the patient, verify first:

Confirm it’s truly non-covered. Check eligibility for the date of service, whether prior auth was required and on file, and whether the right code was billed. PR-96 is sometimes applied in error to services that were covered.
Appeal if you believe it should be covered: a coding correction, an authorization that was actually obtained, or a medical-necessity argument with documentation.
Bill the patient if it is correctly non-covered, but mind the rules. For Medicare you generally need a signed ABN (Advance Beneficiary Notice) on file to hold the patient liable.

PR-96 vs. CO-96

Same reason code, very different consequence. PR-96 puts the balance on the patient. CO-96 makes it a contractual obligation, a provider write-off you cannotbill the patient for. Always read the group code, not just the “96.”

A note for Texas practices

If a PR-96 was applied in error to a service that should have been covered, and the corrected claim then pays late, Texas prompt-pay rules may entitle you to statutory interest on the delayed payment. A “non-covered” label is not always the final word.

The bottom line

PR-96 is a fork in the road: bill the patient, appeal, or write off. The right branch depends entirely on the RARC and a quick eligibility/coding check. Don’t reflexively bill the patient or write it off; a meaningful share of PR-96s are silent denials that should have paid. See also CO-97 and CO-45.

PR-96 Denial Code: Non-Covered Charges, Explained