PR-96: Non-Covered Charges
The patient is responsible for this adjustment amount. Verify the balance and collect from the patient.
What Does PR-96 Mean?
With PR (Patient Responsibility), the amount adjusted under CARC 96 is owed by the patient. The payer determined that this portion — related to non-covered charges — falls under the patient's financial obligation per their plan benefits.
CARC 96 indicates non-covered charges. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.
Common scenarios that trigger this adjustment include: the payer determines that the billed service, procedure, or supply is explicitly excluded from coverage under the patient's policy, including experimental treatments, cosmetic procedures, or alternative therapies; The wrong CPT code, missing modifier, or unsupported diagnosis code was submitted, causing the payer's system to classify a covered service as non-covered; The provider is not in the payer's network and no prior authorization was obtained for out-of-network services, resulting in the charge being classified as non-covered under the contractual terms. The group code paired with CARC 96 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.
Common Causes
| Cause | Frequency |
|---|---|
| Patient informed of non-coverage and accepted responsibility The patient was notified before the service that it was not covered by their plan (e.g., via ABN or financial agreement) and chose to proceed, making the charges their responsibility | Most Common |
| Plan exclusion the patient was aware of The service falls under a known plan exclusion (such as cosmetic procedures) that the patient elected to receive knowing their insurance would not cover it | Common |
| Benefits exhausted for the service category The patient has used all covered visits or benefits for a specific service type and chose to continue receiving the service at their own expense | Common |
How to Resolve
- Verify the adjusted amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the adjustment amount was applied correctly per plan terms.
- Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
- Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the adjustment amount, and the balance the patient owes.
- Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
- Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
This adjustment correctly assigns financial responsibility to the patient per the benefit plan terms. Collect the balance from the patient rather than appealing.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-96:
| RARC | Description |
|---|---|
| N180 | This item/service did not meet the criteria for the category of non-covered charges billed Verify the service meets the payer criteria for the billed category and reclassify if needed → |
| N381 | Consult your contractual agreement for restrictions related to non-covered charges Review your contractual agreement for billing restrictions and payment terms for this service → |
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 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
Sources
- https://www.cms.gov/medicare/coverage/coverage-general-information
- https://www.aapc.com/resources/claim-adjustment-reason-code-carc
- https://medicare.fcso.com/claims/tips-prevent-claim-adjustment-reason-code-carc-pr-96
- https://www.mdclarity.com/denial-code/96
- Codes maintained by X12. Visit x12.org for official definitions.