PR 96 Denial Code|Non-Covered Charges Denial Code

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 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 Does the PR 96 Denial Code Stand For?

It is very essential that one is well aware of the codes to avoid any kind of discrepancy. The PR 96 Denial Code stands for denial for coverage when the patient takes a treatment from an “out-of-network” service provider.

Wondering what this precisely means? This means that there are certain items in the bill which are not covered by your Medicare package. The most common ones include billing of diapers or even surgical dressing.

It is crucial that one checks on these exclusions and then file the claims. If that is not done with efficiency, your claim will come back denied and any of the code which is suitable will be affixed for better understanding. 

It is required that the one sitting in the reception desk explains the details to the patient minutely for better understanding. In most cases it is seen that they do not see the patients unless there is a critical care situation involved.

These codes are most often quite inclusive and upon reading the clauses, you will be able to analyse better as to why your billing might have got denied.

The PR 96 Denial Code stands strongly for the non-covered charges and one has to go through the details to understand what these generally include.

Why are the PR Denial Codes Important?

When you bill a financially liable patient, there are usually two categories- the pr code and the co code. As a hospital you are forbidden to Bill the patients for the co group.

However, you can definitely choose to bill the patient for an adjustment with any item that finds itself in the pr group category. The codes are assigned so that the billing party, as well as the patient both, have a better understanding and hence can move with the process smoothly.

The particular PR 96 Denial Code is a very common one and most often you will notice that there are certain remarks added to the same after they are denied. Once you are well aware of those, it helps with the precise billing.

The clients are also able to understand better why the claim was denied. The codification makes the process much more organized and as a result, much more clarity is noticed.

How to handle PR 96 Denial code

If you are getting the PR 96 non covered charges denial there are some reasons which are mention below

  • Diagnosis or procedure are not covered based on the LCD.
  • Services or procedure performed not covered due to patient current benefit plan.
  • Due Provider contract with insurance company

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 and CO 96 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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