Denial codes · Denial code
PR-204 on a nutrition claim: the plan doesn't cover the service
By Javier Alvarez · Updated · 3 min read
| Official description | This service/equipment/drug is not covered under the patient's current benefit plan |
|---|---|
| Group code | PR: the patient is responsible |
| Related codes | CO-96 (non-covered charges), N130 (see plan documents), N425 (statutorily excluded) |
| Fix route | Usually none on the payer side; check coding before accepting it |
| Patient billing | Allowed, per your financial policy and contract |
| Prevent with | A nutrition-specific benefits check before the first visit |
PR-204 is the payer saying "we don't cover this, and it's between you and the patient." Unlike most denials on this site, there is usually nothing to correct. The work is in making sure it really is an exclusion and not a coding problem, and then handling the patient balance in a way that keeps the patient.
What PR-204 means
The X12 CARC list defines code 204 as:
"This service/equipment/drug is not covered under the patient's current benefit plan"
The PR group code means Patient Responsibility: the payer has assigned the amount to the patient. Compare with:
- CO-96 ("Non-covered charge(s).", always with a remark code): also not covered, but the provider carries the amount.
- PR-119: covered, but the benefit maximum was reached.
- CO-167: the service may be covered, but not for this diagnosis.
Remark codes that may come with it include N130 ("Consult plan benefit documents/guidelines for information about restrictions for this service.") and, for Medicare, N425 ("Statutorily excluded service(s).").
Exclusion or coding problem?
Before billing the patient, spend five minutes ruling out a coding cause:
| Check | Why it matters |
|---|---|
| Which code did you bill? | Some plans cover nutrition only under specific codes, or cover 97802/97803 but not S9470 (or the reverse). A code the plan does not recognize can read as "not covered." |
| Which benefit did it hit? | A plan may exclude nutrition under the medical benefit but cover it as preventive with specific diagnoses. See preventive vs medical benefits. |
| Which provider type? | Some plans cover nutrition counseling only from certain provider types or settings. That can show up as PR-204 or as CO-170. |
| Is it the right plan? | A self-funded employer plan can exclude nutrition even if the insurer on the card usually covers it. The plan document decides; see billing self-funded (ERISA) plans. |
If one of these explains it and the plan does cover the service another way that matches what you actually did, send a corrected claim (frequency code 7 with the original claim number). If the plan simply excludes nutrition counseling, accept the PR-204 and move to the patient.
Handling the patient balance
- Check your contract. Some contracts limit what you can charge members for non-covered services, or require written notice before the visit.
- Use your signed financial policy. The cleanest case is a patient who signed, before the first visit, an agreement that says they pay for services their plan does not cover, with your self-pay rate.
- Bill clearly. Name the visit, the plan's reason ("not covered under your plan") and the amount. Offer a payment plan if you have one.
- Consider the relationship. If the patient was told the visit would be covered (by you or by the plan), a conversation before the statement goes a long way. If your office quoted the wrong benefit, that is worth absorbing or appealing, not passing on.
Medicare is different. For services that are never covered by Medicare (statutorily excluded), the patient can generally be billed. For services Medicare might deny as not reasonable and necessary, you can bill the patient only if you gave a valid ABN before the visit. The rules are on CMS's ABN page.
How to prevent PR-204 surprises
- Ask about nutrition specifically. "Is 97802/97803 by a registered dietitian covered, under which benefit, with which diagnoses, and how many visits?" Active coverage on a 271 does not answer it. Our benefits verification call script has the exact wording.
- Write down the answer with date, representative name and reference number.
- Have every new patient sign a financial policy that covers non-covered services, with your self-pay rate, before the first visit. Our guide to collecting copays and patient balances covers how to set it up.
- Tell the patient before the visit when coverage is uncertain, and offer a self-pay option.
- Re-verify each plan year. Employers change plan designs at renewal, and nutrition coverage is an easy line to cut.
Check what major payers say about nutrition coverage in our insurance coverage guides, and see every other code in the denial code lookup.