PR-96 Denial Code: Non-Covered Charges
The PR-96 denial code means the charge is not covered - the payer classifies the billed item or service outside the benefits it pays for. Payers must include a remark code with it identifying the specific reason (a benefit exclusion, a statutory exclusion, or plan rules), so the RARC alongside PR-96 does most of the explaining. Under the PR group the amount falls to the patient; the same reason code with CO in front makes it a provider write-off instead.
Common Causes
- Statutorily excluded services under Medicare (routine dental, hearing aids, cosmetic procedures)
- Plan-level benefit exclusions - the service exists in the fee schedule but this plan does not buy it
- The diagnosis billed places the service outside coverage (accompanied by remark codes pointing to benefit documents, like N130)
- Items billed to the wrong benefit (a supply that belongs under the DME benefit or pharmacy benefit)
- Coding errors that make a covered service look non-covered - wrong HCPCS code or missing modifier
How to Fix PR-96
- Read the remark code paired with PR-96 to learn the specific exclusion the payer applied
- Verify the correct CPT/HCPCS code was billed - a mis-keyed code can turn a covered service into a non-covered one
- Check whether the service is covered under a different benefit or payer (DME MAC, pharmacy benefit, vision carve-out) and route it there
- If coverage depends on diagnosis, confirm the documentation supports a covered indication and code it specifically before resubmitting
- If the service is genuinely excluded, bill the patient per the plan rules - with a required advance notice (like an ABN for Medicare statutory exclusions) already on file where applicable
Some PR-96 denials are coverage decisions driven by the diagnosis: a service may be covered for certain documented conditions and excluded otherwise. Before treating the balance as patient responsibility, verify the ICD-10 codes on the claim reflect the documented indication at full specificity - a vague or incorrect diagnosis can make a covered scenario look like an exclusion.
Check your codes in the ICD-10 ValidatorFrequently Asked Questions
PR-96 means non-covered charges - the payer classifies the service outside what the plan covers. The remark code sent with it identifies the specific exclusion. As a PR-group denial, the amount is generally patient responsibility.
Same reason (non-covered charge), different liability. PR-96 assigns the balance to the patient; CO-96 makes it a provider write-off - typically when the provider was responsible for knowing the service was not covered or failed to give required notice.
Sometimes. If a coding error made a covered service look excluded, or a covered diagnosis was documented but not billed, correct and resubmit. True benefit exclusions stand - then the question is only whether the patient was properly informed and can be billed.
Related Denial Codes
Related Resources
Claim adjustment reason codes and remittance advice remark codes are standardized code sets maintained by X12. The explanations on this page are written in our own words for educational purposes, based on public CMS and Medicare contractor documentation. Payer policies vary - always confirm handling with the specific payer's guidance and your contracts.