PR-204 Denial Code
What it means
Same as CO-204, but the insurer says YOU are responsible for the cost because it's non-covered.
Why it happens
The item is excluded from your benefits, and the plan is assigning the cost to you.
What to do
Verify the exclusion. Appeal if you believe it should be covered; otherwise ask about a covered alternative or a formulary/medical exception before paying.
Can you appeal it?
Sometimes - via exception or mandate argument.
Official description
This service/equipment/drug is not covered under the plan - patient responsibility.
Decode your full denial letter
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Decode your full denial letterRelated codes
- CO-204 - The item simply isn't a covered benefit under your specific plan....
- PR-96 - page coming soon