PR-204 means the patient's plan does not cover this service, item or drug, and the payer has assigned the amount to the patient. Before billing them, confirm the right codes were used and that the plan really excludes it.
The official wording
The X12 Claim Adjustment Reason Code list defines 204 as: "This service/equipment/drug is not covered under the patient's current benefit plan"
The letters in front are the group code. CO means contractual obligation (the provider absorbs it), PR means patient responsibility, and OA is other adjustment. The same reason code can come with different group codes, so always read both.
What PR-204 is telling you
The plan's benefits do not include this service. With the PR group code, the payer says the patient owes it. If the remittance shows CO-204 instead, check your contract before billing the patient.
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Common causes
- A true exclusion, such as cosmetic services, some vision or hearing services, or weight loss programs.
- A wrong code that looks like an excluded service.
- A benefit the patient's employer did not buy, even though the same payer covers it in other plans.
How to handle it
- Check the codes on the claim against the note.
- Check benefits for that specific plan, not the payer in general.
- If covered, appeal or correct the claim. If not, bill the patient under your financial policy.
How to prevent it
- Check benefits for elective or unusual services before the visit.
- Have patients sign a financial agreement for services their plan may not cover.
One claim, line by line
A patient gets a routine eye refraction during an eye exam. Their plan does not include refractions.
| Line on the remittance | Amount | What it means |
|---|---|---|
| Billed charge for the exam | $150.00 | Covered, paid as normal |
| Billed charge for the refraction | $45.00 | Not a covered benefit |
| PR-204 on the refraction | $45.00 | Patient owes it under your financial policy |
| Paid by payer for the refraction | $0.00 | Plan pays nothing for it |
The patient owes the $45, as long as your coding was right and they were told up front where your policy or state law requires it.
PR-204 vs PR-96 vs CO-204
| Code | Meaning | Who pays |
|---|---|---|
| PR-204 | Not covered under this patient's current plan | Patient |
| CO-204 | Not covered under this plan, but the provider is liable | Provider write-off. Check your contract. |
| PR-96 | Non-covered charge, often for a payer-wide or legal exclusion | Patient. See our PR-96 guide. |
| CO-50 | Covered benefit, but not medically necessary in this case | Usually provider. See our CO-50 guide. |
The key point: 204 is about this patient's plan. The same payer may cover the service in a different employer's plan.
Remark code that often comes with PR-204
| Remark code | Official wording | What to do |
|---|---|---|
| N130 | "Consult plan benefit documents/guidelines for information about restrictions for this service." | Pull the plan's summary of benefits and confirm the exclusion before you bill the patient. See our N130 guide. |
How to post PR-204
- Check the codes against the note. A wrong code can look like an excluded service.
- Confirm the exclusion in the plan's benefit documents.
- If a secondary plan exists, send the claim there with the primary EOB.
- Move the amount to patient balance and send a clear statement.
- If the service is covered, send a corrected claim or appeal with the benefit language.
PR-204 checklist
- ☐ The CPT and diagnosis codes match the note.
- ☐ The plan's benefit documents confirm the exclusion.
- ☐ Any secondary plan has been billed.
- ☐ The patient signed a financial agreement or notice if your policy requires one.
Questions people ask about PR-204
Can I bill the patient for PR-204?
Yes, PR means patient responsibility. Check the coding first.
What remark codes come with PR-204?
Often N130, which tells you to check the plan's benefit documents for restrictions.
What is the difference between PR-204 and PR-96?
Both put the cost on the patient. PR-204 says this patient's plan does not include the service. PR-96 is a broader non-covered charge, often for services excluded across the plan or by law.
What if the remittance shows CO-204 instead?
CO means the provider is liable. Check your contract before billing the patient. In most in-network cases you cannot bill them.
Can a secondary plan pay a PR-204?
Yes, if the secondary plan covers the service. Send it with the primary EOB before billing the patient.
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All denial code guides
PR-1 · PR-2 · PR-3 · CO-4 · CO-5 · CO-11 · CO-15 · CO-16 · OA-18 · CO-22 · OA-23 · CO-24 · CO-26 · CO-27 · CO-29 · CO-31 · CO-45 · CO-49 · CO-50 · CO-59 · PR-96 · CO-97 · CO-109 · CO-119 · CO-129 · CO-140 · CO-146 · CO-151 · CO-167 · CO-170 · CO-181 · CO-185 · CO-197 · CO-198 · PR-204 · CO-234 · CO-236 · CO-242 · CO-252 · CO-253 · CO-288 · CO-A1 · CO-B7 · MA130 · N130 · N23 · N290
Timely filing limits by payer: Cigna timely filing limit · HealthSpring timely filing limit · Aetna timely filing limit · UnitedHealthcare timely filing limit · Humana timely filing limit · corrected claim timely filing limits
Sources: X12 Claim Adjustment Reason Code list (204), read October 27, 2026; CMS Medicare guidance where Medicare rules are mentioned; X12 Remittance Advice Remark Code list (N130), read October 27, 2026. Last reviewed October 27, 2026. General information, not coding or legal advice. Payer rules differ, so check the remark code and the payer's own policy.