PR-204: not covered under the patient's benefit plan
The plan does not cover this item, and the payer is assigning the cost to the patient.
This service/equipment/drug is not covered under the patient's current benefit plan.
What the PR group code means
PR — Patient Responsibility
The amount moves to the patient — deductible, copay, coinsurance, or a non-covered service they agreed to.
Is it worth appealing?
Worth challenging when the item should be covered under the plan and the payer misclassified it. When the plan genuinely excludes it, the amount is properly the patient's — and the question becomes whether they were told before the service.
Why payers issue PR-204
- 01The plan genuinely excludes the item or service.
- 02The payer assigned it to the wrong benefit category.
- 03The item required a prior determination that was never obtained.
- 04The plan covers it only under conditions the claim did not establish.
What to gather before you appeal
- The member's plan document or summary of benefits for the date of service.
- The payer's coverage policy for the item.
- Any advance notice of non-coverage signed before the service.
- Documentation of medical need, where coverage is conditional.
Arguments that work
- The plan does cover this item and the payer applied the wrong benefit category.
- The conditions for coverage were met and are documented.
- The exclusion the payer cited does not appear in the plan document.
The deadline
Standard appeal windows apply. If the exclusion holds, move promptly to patient billing — and check that a valid advance notice exists before doing so.
Common questions about PR-204
- Can I bill the patient for PR-204?
- Yes, that is what the PR group code means. But confirm the patient was informed before the service — billing someone for a non-covered item they were never warned about is how these become disputes.
- Is PR-204 worth appealing?
- Only when you have reason to think the item should be covered. Read the plan document rather than the denial: payers sometimes classify an item into the wrong benefit category, and that is a real and winnable argument.
Draft the PR-204 appeal in about three minutes
Upload the denial. Undeny reads it, drafts a payer-specific appeal letter citing this code and the record, and tracks the deadline until the money comes back.
Other denial codes
- CO-197CO-197 denial: prior authorization absent
- CO-16CO-16 denial: claim lacks information
- CO-29CO-29 denial: timely filing limit expired
- CO-45CO-45: charge exceeds fee schedule
- CO-50CO-50 denial: not deemed medically necessary
- CO-97CO-97 denial: service already included in another payment
- CO-18CO-18 denial: exact duplicate claim
- CO-22CO-22 denial: another payer is primary
- CO-27CO-27 denial: coverage terminated before the service
- CO-96CO-96 denial: non-covered charges
- CO-109CO-109 denial: claim sent to the wrong payer
- CO-151CO-151 denial: too many services billed
- CO-B7CO-B7 denial: provider not eligible on the date of service
- CO-4CO-4 denial: modifier inconsistent or missing
- CO-11CO-11 denial: diagnosis inconsistent with the procedure
- PR-1PR-1: deductible amount — and why it is not a denial