Denial Code PR-200
Expenses incurred during lapse in coverage
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PR-200 means
The service fell during a gap in the patient's coverage — a period when no plan was active — so the plan won't pay and the balance is the patient's. Confirm the lapse dates before billing.
Why PR-200 happens
- A premium non-payment lapse that suspended coverage on the date of service
- A gap between an old plan ending and a new plan starting
- Coverage retroactively terminated for a period that includes the service date
- A reinstatement that hadn't taken effect on the date of service
What to do when you get PR-200
- 1Verify the coverage lapse dates against the date of service
- 2Check whether coverage was later reinstated retroactively to include the date of service
- 3If another plan was active during the gap, refile to that payer
- 4If the lapse is confirmed and no other coverage applies, bill the patient
Got this denial right now?
Generate a patient-balance explainer letter — free
PR-200 is the patient's responsibility. Generate a clear, plain-English balance letter — free, no signup.
PR group code: who absorbs the charge
Patient Responsibility — May be billed to the patient.
A PR adjustment is the patient's liability — a deductible, coinsurance, copay, or a non-covered amount the patient owes. It is collectible directly from the patient, ideally after advance notice for any non-covered service.
Appeal, correct, or write off PR-200?
PR-200 is generally correct when coverage was genuinely lapsed — the balance is the patient's. Rule out a fixable cause first: a retroactive reinstatement, a wrong lapse date, or replacement coverage that should be billed. Appeal only if the patient was actually covered on the date of service (e.g., coverage was reinstated to that date) and the payer's record is wrong.
Timing & deadlines
If refiling to a payer that covered the gap, mind that payer's timely-filing limit (~90-180 days commercial; Medicare 12 months from date of service). There is no payer deadline on collecting a legitimate PR balance from the patient.
Example
A patient's coverage lapsed for non-payment during the month of service, and the payer returns PR-200. If the patient later pays premiums and coverage is reinstated retroactively, the claim can be reprocessed; otherwise the visit is the patient's responsibility.
Prevent PR-200 going forward
- Run eligibility before each date of service to catch active lapses
- Ask patients about premium status and coverage gaps at check-in
- Capture replacement coverage when a plan lapses or ends
- Re-verify eligibility after any reported reinstatement
Code families most affected
- Services during premium-lapse or coverage-gap periods
- Patients between plans
- Claims affected by retroactive termination/reinstatement
Related codes
Payer notes
PR-200 (lapse in coverage) is close kin to PR-27 (after coverage terminated). Both become the patient's responsibility once you confirm no coverage — including retroactive reinstatement or replacement coverage — applies to the date of service.
Explain this PR-200 balance to your patient
PR-200 is a patient-responsibility balance. D3rx drafts a clear, plain-English patient-balance explainer for PR-200 — free, no signup.
Medical billing disclaimer
CARC/RARC definitions are the standardized X12 set; group-code semantics follow the X12 Claim Adjustment Group Code standard. Filing and appeal windows vary by payer — the standard anchors shown (Medicare redetermination 120 days from the remittance; Medicare timely filing 12 months from date of service; most commercial payers ~90-180 days) are general references, not a guarantee for any specific plan. Always confirm the rule in the payer's provider manual before acting. D3rx is not responsible for claim outcomes.