PR-242: Services Not Provided by Network/Primary Care Providers
The patient owes because they used an out-of-network provider. Collect from the patient.
What Does PR-242 Mean?
With PR, the patient is responsible because they obtained services outside their network or without a PCP referral. Collect from the patient.
CARC 242 indicates that the service was rendered by a provider who is outside the patient's required network or is not the patient's designated primary care provider, and the patient's plan requires these services to come from network or PCP providers. This is common in HMO and gatekeeper plans where patients must use in-network providers and obtain services through or under the direction of their assigned primary care provider.
The denial means the plan does not cover services from out-of-network providers or non-PCP providers for this service type. The patient may need to receive the service from their designated network provider, or obtain a referral from their PCP.
Common Causes
| Cause | Frequency |
|---|---|
| Patient chose out-of-network provider The patient elected to receive services from an out-of-network provider and is responsible for the higher out-of-network cost or the full amount | Most Common |
| Patient did not obtain required referral The patient failed to get a referral from their PCP before seeing a specialist | Common |
How to Resolve
- Verify the network issue Confirm the provider is out-of-network for the patient's plan.
- Communicate with the patient Explain the network requirement and the resulting financial responsibility.
- Collect from the patient Send a statement and collect.
The services were provided by an out-of-network or non-primary care provider. The patient is responsible for the cost per their plan terms. Collect the balance from the patient.
How to Prevent PR-242
- Verify network status at scheduling and inform patients of out-of-network costs
- Help patients obtain PCP referrals before scheduling specialist visits
General Prevention
- Educate patients about their plan's network and referral requirements
- Help patients find in-network providers when possible
- Provide cost estimates for out-of-network services before delivery
Also Filed As
The same CARC 242 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- https://www.mdclarity.com/denial-code/242
- 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
- Codes maintained by X12. Visit x12.org for official definitions.