CARC 304 Active

PR-304: Medical Plan Claim — Submit to Hearing Plan

TL;DR

The patient is temporarily responsible. Resubmit to the hearing plan before collecting.

Action
Verify & Resubmit
Who Pays
Patient
Appeal
Yes
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-304 Mean?

The patient is financially responsible until the claim is processed by the correct hearing plan. The patient should not be balance-billed until the hearing plan has had an opportunity to adjudicate.

CARC 304 appears when the medical plan determines the billed service falls under hearing coverage rather than the medical benefit. Insurers that use hearing benefit carve-outs separate hearing services from the medical plan. When the medical plan identifies a claim as hearing-related — such as audiometry, hearing aid fitting, or cochlear implant services — it denies coverage and directs the provider to submit to the hearing plan.

This code functions similarly to CARC 301 (behavioral health redirection) but applies specifically to hearing services. It can also appear when procedure or diagnosis codes on the claim cause the medical plan's classification logic to categorize the service as hearing-related, even if the provider views the service as primarily medical.

Common Causes

Cause Frequency
Patient responsible until correct plan processes claim Medical plan assigned patient responsibility for hearing services pending submission to the hearing plan Most Common
Hearing services not covered by any plan Patient's medical plan does not cover hearing services and the patient does not have a separate hearing plan Common

How to Resolve

  1. Inform the patient that the claim must be submitted to their hearing plan
  2. Assist the patient in identifying their hearing plan details
  3. Resubmit the claim to the hearing plan on behalf of the patient
  4. If the service is medical, appeal the denial with clinical documentation
Appeal Guide

Appeal with clinical documentation showing the service is medical, not hearing-related, to support coverage under the medical plan.

How to Prevent PR-304

Also Filed As

The same CARC 304 may appear with different Group Codes:

CO-304 OA-304

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/304
  3. https://www.cms.gov/medicare/payment/prospective-payment-systems
  4. Codes maintained by X12. Visit x12.org for official definitions.