PR-258: Claim Not Covered - Patient in Custody or Incarcerated

What Does PR-258 Mean?

When paired with Group Code PR, CARC 258 shifts the financial responsibility to the patient. The adjustment for claim not covered - patient in custody or incarcerated is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.

CARC 258 appears when a payer denies a claim because the patient was identified as being in custody or incarcerated at the time the service was rendered. Under most insurance policies, Medicaid rules, and commercial plan terms, coverage is suspended or excluded during periods of incarceration because the custodial authority — the federal Bureau of Prisons, state Department of Corrections, or local jail system — assumes responsibility for the inmate's healthcare.

The most common trigger is the federal Medicaid inmate exclusion, which prohibits Medicaid payment for services provided to incarcerated individuals. Some states allow an exception for inpatient hospital stays of 24 hours or more, but outpatient services are generally excluded. Commercial insurers may also have policy provisions that suspend coverage during custody periods.

CARC 258 appears with Group Code CO, indicating the denial is a contractual adjustment. However, the resolution path depends on whether the patient was actually in custody. If the patient was not incarcerated on the date of service — perhaps they had been released before the encounter or the payer's data is outdated — the provider should appeal with documentation proving the patient's non-custody status. If the patient was genuinely incarcerated, the provider should submit the claim to the responsible government custodial authority.

How to Resolve

1. Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 258 adjustment. Review the remittance advice and any RARC codes for context.
2. Review for potential errors Check whether the underlying denial reason can be corrected, which may eliminate the patient's responsibility. Verify coding accuracy and documentation completeness.
3. Appeal if designation is incorrect If the PR assignment appears incorrect or the denial is in error, file an appeal with supporting documentation before billing the patient.
4. Generate patient statement If the determination is correct, generate a patient statement for the amount and follow standard patient collection procedures.
5. Communicate with the patient Explain the charge to the patient, provide information about their financial responsibility, and discuss payment options.

How to Prevent PR-258

• Verify patient coverage and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively
• Review PR-258 adjustments before billing to confirm the designation is appropriate

Also Filed As

The same CARC 258 may appear with different Group Codes:

Related Denial Codes