CARC 204 Active

PR-204: Service/Equipment/Drug Not Covered Under Benefit Plan

TL;DR

The patient owes for the non-covered service. Collect the full amount from the patient.

Action
Collect from Patient
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-204 Mean?

With PR (Patient Responsibility), the patient is financially responsible for the non-covered service. The service is not part of the patient's benefit package and the patient must pay the full cost out of pocket. Collect from the patient.

CARC 204 indicates that the billed service, drug, or equipment is explicitly excluded from the patient's benefit plan. Unlike denials for medical necessity (where the service type is covered but the specific use was not justified), this code means the entire category of service or specific item is not part of the plan's covered benefits.

This denial commonly occurs when a medication is not on the plan's formulary, DME is excluded from the benefit package, the plan has a benefit cap that has been reached, or the service requires prior authorization that was not obtained. Understanding the specific reason for non-coverage is essential for determining the correct resolution path.

Common Causes

Cause Frequency
Patient's plan does not cover the service The service is not part of the patient's benefit package and the patient is financially responsible for the full amount Most Common
Patient chose non-covered option The patient elected a non-covered service, drug, or equipment when a covered alternative was available Common

How to Resolve

  1. Confirm non-coverage Verify the service is genuinely not covered under the patient's plan.
  2. Communicate with the patient Inform the patient of the non-coverage and their financial responsibility.
  3. Collect from the patient Send a statement and collect the balance. Offer payment plan options for large amounts.
Do Not Appeal This Code

This service, equipment, or drug is not covered under the patient's current benefit plan. The patient is financially responsible for the full cost. Collect the balance from the patient.

How to Prevent PR-204

Also Filed As

The same CARC 204 may appear with different Group Codes:

CO-204 OA-204

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/204
  3. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  4. Codes maintained by X12. Visit x12.org for official definitions.