PR-96: Non-Covered Charges

What Does PR-96 Mean?

PR-96 shifts the non-covered charge to the patient. This typically means the patient was informed before the service that it was not covered — via an ABN, waiver, or financial responsibility agreement — and chose to proceed. The provider can and should collect the full PR-96 amount from the patient. This group code also applies when benefits have been exhausted for a service category and the patient chose to continue receiving care at their own expense.

CARC 96 is the payer's way of communicating that one or more charges on your claim fall outside the patient's coverage. This is a coverage-based denial, not a billing error or medical necessity dispute — although coding errors can trigger it when a covered service is submitted with the wrong code and gets reclassified as non-covered. The X12 standard requires at least one Remark Code to accompany CARC 96, so always check the RARC before taking any action.

The scope of non-covered charges is broad. It includes services explicitly excluded by the plan (cosmetic procedures, experimental treatments, alternative therapies), services that exceeded a plan-imposed limit (such as a cap on physical therapy visits per year), services from out-of-network providers without proper authorization, and services rendered after coverage has lapsed or been terminated. A service that is normally covered can also be adjudicated as non-covered if the submitted code set contains an excluded procedure code, a missing modifier, or an unsupported diagnosis.

The group code pairing is especially important with CARC 96. CO-96 assigns the non-covered charge to the provider as a contractual write-off — which means you cannot bill the patient unless you obtained an Advance Beneficiary Notice (ABN) before the service. Without a signed ABN on Medicare claims, the provider absorbs the cost entirely. PR-96 means the patient accepted financial responsibility, typically because they were informed the service was not covered and chose to proceed. Understanding this distinction is critical for correct financial posting and patient billing.

Common Causes

How to Resolve

Read the RARC to identify the specific reason for non-coverage, then either correct and resubmit, write off, or bill the patient based on the group code.

1. Confirm patient acknowledgment Verify that the patient signed an ABN or financial agreement before the service. This document is your basis for billing the patient.
2. Transfer to patient A/R Move the PR-96 amount from insurance receivables to the patient responsibility ledger. Generate a patient statement showing the service, the non-covered amount, and the reason.
3. Contact the patient and arrange payment Explain the non-covered charge to the patient, confirm the amount owed, and offer payment options. For larger balances, offer a payment plan.
4. Follow your patient collections workflow Enter the balance into your standard patient collections cycle. Track separately from insurance denials since this is a patient obligation.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-96:

How to Prevent PR-96

• Inform patients of non-covered services and obtain written acknowledgment of financial responsibility before providing the service
• Use cost estimation tools to give patients accurate out-of-pocket amounts for services that may not be covered
• Train front desk staff to explain plan limitations and exclusions during registration and scheduling
• Maintain up-to-date ABN templates and ensure consistent use for all potentially non-covered services

General Prevention

• Use cost estimation tools to provide patients with expected out-of-pocket amounts for services that may not be covered
• Train front desk staff to explain plan limitations and exclusions to patients during registration and scheduling
• Maintain ABN templates and ensure they are used consistently for all potentially non-covered services

Also Filed As

The same CARC 96 may appear with different Group Codes:

Related Denial Codes