Denial Code PR 204 Description (2024)

We have already discussed with great detail that the denial code stands as a piece of information to the patient of the claimant party stating why the claim was rejected. Today we discussed PR 204 denial code Description in this article.

Denial Code PR 204- “This service, equipment and-or drug is not covered under the patient’s current benefit plan.“

When it comes to the PR 204 denial code, it usually indicates all those services, medicines, or even equipment that are not covered by the claimant’s current benefit plan and yet have been claimed.

For example, if you supposedly have a gallbladder operation and your current insurance plan does not cover that claim, it will come rejected under the denial code PR 204.

Another specification that could be covered under the same segment is that the claimed product or service was not medically required at the moment and hence the claim will not be passed.

Most insurance companies have their own experts and they are the people who decide whether or not a particular service or product is important enough for the patient.

What to Do If You Find the PR-204 Denial Code for Your Claim?

If your claim comes back with the denial code 204 that is really nothing much that you can do about it. In case you are very sure and your agent also says that the plan or product is covered under your medical claim and the rejection has been made on the wrong grounds, you can contact the insurance company at the earliest.

In most cases, there is no stand for confusion because all the inclusions, as well as exclusions, are mentioned in detail in the policy papers. However, in case of any discrepancy, you can always get back to the company for additional assistance.

The denial code 204 is unique to the mentioned condition. Hence, before you make the claim, be sure of what is included in your plan.

How to handle PR-204 Denial Code in Medical Billing

If you received the denial on the claim that PR 204 or Co 204 – service, equipment and/or drug is not covered under the patient’s current benefit plan, in that case, if pat has secondary insurance then claim billed to sec insurance otherwise claim bill to the patient because the patient is responsible if any service is not covered under the patient insurance plan.

• Routine physical exams are generally not covered by Medicare, except for specific cases such as the “Welcome to Medicare” physical or the “Initial Preventive Physical Exam” (IPPE).
• Providers are not required to submit claims for services excluded by statute under Section 1862(a)(1) of the Social Security Act.
• If a patient believes a service may be covered and requests a claim or desires a formal Medicare determination, a claim must be filed for that service.
• Non-covered services can be submitted to Medicare for denial purposes using the HCPCS modifier GY, indicating that the item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
• CMS has introduced new Advance Beneficiary Notice (ABN) forms, which incorporate the language previously used in the “Notice of Exclusion from Medicare Benefits” (NEMB).
• The revised ABN is optional for services excluded from Medicare benefits.
• The Palmetto GBA Modifier Lookup tool can provide information on HCPCS modifiers GY or GA.
• Staying updated with CMS guidelines and resources is essential for accurately handling Medicare coverage and claim submission.

FAQ- Frequently Asked Questions

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