Wondering what this term means? Well, if you are someone who is not aware of medical billing, these few words might seem alien to most! But the PR Denial Code descriptions is exceptionally important for medical billing and the full form for PR stands for “Patient Responsibility”. PR 96 Denial code means non-covered charges.
When the billing is done under the PR genre, the patient can be charged for the extended medical service. Most often this kind of billing is done for those items which can be covered by the patient easily and the list is given before any kind of coverage is issued.
The code is simply given to classify such situations in a more detailed proforma.
What is PR96 Denial Code Stand For?
In the complex landscape of medical billing, denial codes are crucial indicators that provide insight into the reasons behind claim rejections. Denial Code PR96 means to Non-Covered Charges or services performed are no covered due to some reason. This denial code manifests in two distinct scenarios, the 2 scenarios are mentioned as below.
A- Non covered charges due to patient plan
B- Non covered due to providers contract
Non-Covered Charges as per Patient Plan:
Denials falling under this category are primarily rooted in discrepancies between the services rendered and the patient’s insurance coverage. The following scenarios may trigger this denial:
- Provider is Out of Network:
- Patients often have specific networks within which their insurance coverage is applicable. When a healthcare provider is outside this network, it may lead to non-covered charges.
- Non-Covered DX or ICD-10 Code under Patient Policy:
- Insurance plans outline covered diagnosis (DX) or ICD-10 codes. If the code associated with the medical service is not covered under the patient’s policy, the claim may be denied.
- Non-Covered CPT Code under Patient Policy:
- Current Procedural Terminology (CPT) codes play a pivotal role in billing. If a specific CPT code is not covered under the patient’s policy, the claim can be denied.
Non-Covered Charges as per Provider Contract:
In this category, the denial is related to the agreement between the healthcare provider and the insurance company. The denial occurs specifically when the CPT code associated with the service is considered non-covered under the provider contract.
Explanation:
For healthcare providers and billing specialists, navigating these denial scenarios requires a thorough understanding of both the patient’s insurance plan and the provider contract. Addressing and preventing PR 96 denials involve a proactive approach:
- Verification of Network Participation:
- Providers must regularly verify their network participation status with insurance companies. Staying within the specified network ensures that services are covered under the patient’s plan.
- Accurate Coding Practices:
- Accurate coding is fundamental in preventing denials. Ensuring that the diagnosis and procedure codes align with the patient’s policy can significantly reduce the risk of PR 96 denials.
- Contract Review and Negotiation:
- Periodic reviews of provider contracts can help identify any discrepancies in covered services. Negotiating contracts to include a broader range of covered services can be a proactive measure.
- Education and Communication:
- Patient education about network restrictions and coverage details can mitigate potential denials. Clear communication with patients regarding non-covered services helps manage expectations.
In the realm of medical billing, Denial Code PR 96 serves as a critical signal for providers to assess and refine their billing practices. By addressing the specific reasons for non-covered charges as per the patient’s plan and provider contract, healthcare professionals can enhance their revenue cycle management and provide better financial outcomes for both the practice and the patients.
How to Handle PR96 Denial code:
Here’s a step-by-step guide for handling a denial as a Medical Billing expert:
- Identify Denial Reason:
- Upon receiving a claim denial with the reason “Non Covered Charges,” the first step is to determine the specific cause for the denial.
- Determine Denial Date:
- Inquire about the denial date to have a clear timeline for further actions.
- Patient Plan or Provider Contract:
- Establish whether the denial is based on the patient’s insurance plan or the provider’s contract with the insurance company.
- If it’s non-covered as per the patient’s plan:
- Find out the reason for non-coverage.
- If it’s the provider being out of network, proceed to address this.
- If it’s related to DX or ICD-10 codes, explore further.
- For other reasons, identify and address them accordingly.
- Find out the reason for non-coverage.
- If it’s non-covered as per the provider contract:
- Determine the reason for non-coverage.
- If it’s specific CPT codes, proceed accordingly.
- For other reasons, investigate and address each one.
- Determine the reason for non-coverage.
- Provider Out of Network:
- If the denial is due to the provider being out of network, consider negotiating with the insurance company or explore options to bring the provider in-network.
- DX or ICD-10 Non-Covered:
- If the denial is related to DX or ICD-10 codes not being covered, review the codes and check for accuracy. If needed, submit corrected information or corrected claim and asked to reprocess the claim.
- CPT Non-Covered Under Provider Contract:
- If specific CPT codes are non-covered under the provider contract, assess the situation and consider negotiating with the insurance company or exploring alternatives.
- Other Reasons for Non-Coverage:
- If the denial is due to other reasons, identify each one and address them individually.
- Check Payment History:
- Verify the payment history to ensure that no payment has been received for the same CPT code from the same insurance company.
- Follow AR Scenario Tool:
- If necessary, follow the Accounts Receivable (AR) scenario tool to guide your actions based on the specific circumstances.
- Submit Corrected Claim:
- If required, submit a corrected claim with the necessary information or documentation.
- Appeal Process:
- If the denial persists, initiate the appeal process.
- Confirm the appeal limit.
- Obtain the necessary information, including the fax number or address for submitting the appeal.
- If applicable, inquire about the time frame for reprocessing.
- If the denial persists, initiate the appeal process.
- Reprocessing the Claim:
- If the insurance company agrees to reprocess the claim, proceed with the necessary steps.
- Obtain the claim number and call reference number for tracking purposes.
- If the insurance company agrees to reprocess the claim, proceed with the necessary steps.
- Appeal Denial:
- If the appeal is denied, assess the situation and determine the next course of action.
- Document Everything:
- Throughout the process, document all communications, dates, and actions taken. This documentation is crucial for tracking the progress and providing a clear record of the efforts made.
- Follow Up:
- Periodically follow up on the status of the appeal or reprocessed claim to ensure timely resolution.
By following these steps, you can systematically address and navigate through the denial process as a Medical Billing expert.
In this denial some times clear instructions available in SOP about some specific diagnosis codes or procedure codes and take action according to SOP.
In some cases we do not have the clear information in that case called to insurance company and ask rep for what is exact denial reason and which Dx or CPT denied due to PR 96 (Non Covered charges) and take action as per requirements.
Note- PR-96 denial code and CO96 is same denial and handled in same manner. Here CO means contractual obligation and PR means patient responsibility. For more info about CO and PR Click here
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