PR-96 Denial Code: Non-Covered Charges and Insurance Billing Solutions

As a medical biller or revenue cycle manager, chances are that you've encountered the infamous PR-96 denial code before. What makes this denial especially frustrating is the fact that it usually surfaces in claims that have been submitted accurately, coded properly, and billed on schedule. However, in such situations, the issue lies not with the process but the coverage.

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Knowing what the PR-96 denial code really is, why it happens, and how it can be avoided or appealed is absolutely vital information for any billing team in 2026. In this article, we cover everything from CARC and RARC codes to typical PR-96 scenarios and ways to deal with them.

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What Is the PR-96 Denial Code?

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PR-96 denial code is a Claim Adjustment Reason Code (CARC) used by health insurance companies to show that the service or supply is not eligible under the existing benefit plan of the patient. PR indicates “Patient Responsibility,” meaning the denied amount may be transferred to the patient based on payer rules, provider contracts, and whether appropriate patient notifications (such as ABNs for Medicare) were obtained.

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The complete definition of the CARC 96 code is as follows:

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“Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).”

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The second part of the definition is very important because the CARC 96 should never be used independently. There should be at least one Remittance Advice Remark Code (RARC) along with the CARC 96 code.

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Common RARC Codes Paired with PR-96

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Because CARC 96 requires an accompanying RARC, understanding the most common pairings helps your team diagnose the root cause quickly. Here are the RARC codes most frequently seen with PR-96 in 2026:

Always read both the CARC and RARC together. The CARC tells you the category of the denial; the RARC tells you the specific reason within that category. Acting on CARC 96 without reading the RARC is like treating a symptom without diagnosing the disease.

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Why Does the PR-96 Denial Code Get Triggered?

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PR-96 denial codes can be found across many scenarios. The most frequently cited ones can be categorized as follows:

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1. Service Not Covered Under the Patient's Plan

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Some services are specifically excluded from the patient's benefits plan altogether. These include any cosmetic procedures, experimental treatment methods, certain wellness services, hearing aid fittings, routine dental care procedures when billed through a medical payer, and some nutrition consultation services. The service might very well be necessary, but if it is not included in the covered benefits, it will automatically generate a PR-96 denial. In some payer systems, CARC 204 (“This service/equipment/drug is not covered under the patient’s current benefit plan”) may also be used instead of CARC 96, depending on payer adjudication logic.

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2. Frequency Limitations Reached

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Some insurance programs limit preventive care and therapies in terms of how many times they can be performed each year. Physical therapy treatments, chiropractic adjustments, and mental health therapy sessions, among others, often have frequency limits that, once reached, will deny claims via PR-96.

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3. Absence or Invalidation of a Prior Authorization Requirement

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There are some costly services that need to be authorized before payment is made. If the authorization was never obtained, no longer valid, or issued for another service, the insurer will return the claim with PR-96 denial code and a remark about prior authorization.

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4. Inaccurate Coding Causing an Uncovered Benefit Service

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CPT/HCPCS codes that do not accurately describe the performed service might result in a benefit service that is not covered due to PR-96. For instance, coding a surgical procedure for cosmetic indications instead of reconstructive use may cause the PR-96 denial. Proper coding based on documented clinical indications is essential to avoid the issue.

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5. Coordination of Benefits Situations

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In coordination of benefits (COB) situations, a primary payer may deny a service as non-covered, after which the claim can be submitted to the secondary payer for further adjudication based on that plan’s coverage rules.

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6. Insurance Plan Design Exclusions

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Some plans, like HDHPs, HMOs, or some marketplace plans, may have different exclusions compared to traditional PPO plans. For instance, a patient can receive services under an employer's plan, but after receiving another type of coverage from a new employer, services will no longer be covered due to PR-96.

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How to Fix a PR-96 Denial & How to Appeal It

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The approach to resolving a PR-96 denial depends on the root cause. Here is a structured resolution framework:

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• Step 1 – Before taking any steps, read the complete RARC(s) that go with the PR-96 code.
• Step 2 – Check if the patient meets the criteria and has the specific benefits covered on the date of service.
• Step 3 – Check your clinical notes to see if the CPT/HCPCS code matches the service provided.
• Step 4 – Check if there was an obligation to obtain prior authorization and if this process was followed.
• Step 5 – If there was a coding mistake that resulted in the denial, fix the code and send it again.
• Step 6 – If the service is truly non-covered and patient billing is permitted under payer and regulatory rules, notify the patient and issue the appropriate financial responsibility documentation.
• Step 7 – In case you think that the PR-96 denial is wrong, appeal the decision.
• Step 8 – If the PR-96 denial applies to Medicare patients, find the relevant LCD and send in supporting documents.

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Preventing PR-96 Denials Proactively

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The best strategy for dealing with PR-96 denials is avoiding their occurrence altogether. Upstream strategies greatly decrease the occurrence of non-covered charges:

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Real-Time Eligibility Verification

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Perform eligibility verifications when you schedule the appointments and the day before the actual service is performed. Most modern practice management systems and clearinghouses support electronic 270/271 eligibility transactions that allow teams to verify coverage and benefits quickly before services are rendered. Check not only that the patient is covered but also what benefits the plan provides, including which services are covered, excluded, frequency limitations, and co-pay responsibilities.

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Benefits Verification for Pre-Service

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Eligibility tells you that the patient has insurance. Benefits verification tells you if the particular service to be rendered is covered. If there is any suspicion that the particular service will not be covered by the insurance policy, then call the carrier or use its website to verify in writing.

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Advance Beneficiary Notices for Medicare Patients

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For Medicare patients, providers should issue a valid Advance Beneficiary Notice of Noncoverage (ABN) before rendering services that are expected to be denied due to medical necessity or frequency limitations if they intend to bill the patient. Medical necessity denials may also appear under PR-96 depending on payer policy, especially when diagnosis codes do not support coverage criteria outlined in LCDs or commercial medical policies.

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Accurate Coding with Proper Documentation Support

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It is critical that your coders are working off of proper documentation. The diagnosis codes must accurately reflect the medical necessity of all services performed. The procedure codes should be aligned with the service performed. Misalignment of what happened clinically versus what was coded can be a top reason why a claim gets denied through the PR-96 process.

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Payer-Specific Contract and Policy Reviews

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The coverage policy by payers changes yearly. Develop a consistent review process within your organization to identify any changes to the payer LCDs, NCDs, and benefits offered by commercial plans. LCDs, NCDs, and commercial payer policies are updated regularly and may change annually or quarterly, depending on the payer and service category.

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How RapidClaims Helps You Manage PR-96 Denials

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Denial management at scale demands more than just following an itemized list. The RapidClaims software has been designed to provide your revenue cycle teams with all the necessary functionalities for lowering PR-96 denial rates, spotting patterns, and addressing unresolved claims faster.

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These include:

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• Automated eligibility and benefits checks directly within the pre-service process
• Coding assistance that detects any denial risks among the submitted code sets
• Denial analysis that shows PR-96 denial trends according to payer, service, provider, and period
• Workflows for appeals with an automated document checklist according to the denial codes and payers
• Routing functionality that automatically allocates denied PR-96 claims to the proper team member according to the payer and denial code

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The RapidClaims platform saves your billing team valuable time that would otherwise be spent manually looking up denial codes, so that you can take appropriate actions on the claims that could be recovered.

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The PR-96 denial code is a signal, not a dead end. It tells you that a payer has identified a service as non-covered under the patient's current plan, but it does not automatically mean the claim is unrecoverable or that the patient cannot be billed. The key is in understanding exactly what triggered it, reading the accompanying RARC carefully, and taking the right action, whether that means resubmission with corrected coding, a formal appeal, or a patient statement.

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The PR-96 denial code does not have to be a recurring drain on your revenue. With the right knowledge and the right tools, it is a manageable, reducible part of your denial landscape.

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FAQs

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Q1. What is Denial Code PR-96?

PR-96 is a Claim Adjustment Reason Code (CARC) that signals the payer that the service billed, the procedure performed, and/or the supply supplied was not part of the covered benefits according to the patient’s insurance benefit plan. The “PR” prefix means that the denial amount could eventually become the financial obligation of the patient based on various payer guidelines, contractual arrangements, and the necessary communication between the provider and the patient before rendering the service.

Q2. What is the official description of the PR-96 denial code?

The official description for CARC 96 is: “Non-covered charge(s). At least one Remark Code must be provided.” This means the payer has determined that the submitted charge is not eligible for reimbursement under the patient’s plan.

Q3. Why is there a PR-96 denial code?

There can be multiple reasons for a PR-96 denial code, but most commonly, the billing service was not included in the covered benefits according to the patient’s plan, or it failed to meet the payer’s criteria.

Q4. Are providers permitted to charge patients for PR-96 denials?

Providers will be able to charge patients for PR-96 denials if it is within their policy, contract terms, and regulations. In most cases where Medicare patients file PR-96 denials, providers have to provide an Advance Beneficiary Notice of Noncoverage (ABN).

Q5. How can billing teams address PR-96 denials or prevent them?

Billing teams can address PR-96 denials and prevent future denials by checking on patient eligibility, benefits, prior authorizations, and proper codes.