Denial Code PR-242

What PR-242 means

The services weren't provided by an in-network (or the required primary-care) provider, and under the PR group code the balance is the patient's — typically because the patient chose to go out-of-network or bypassed required coordination.

Why PR-242 happens

• The patient knowingly received care from an out-of-network provider
• A gatekeeper plan's primary-care coordination/referral wasn't followed by the patient
• Care outside a narrow-network panel the patient elected
• Out-of-network services where the plan assigns the balance to the member

What to do when you get PR-242

1. 1Confirm the provider's network status and that the patient was responsible for the choice
2. 2Check whether No Surprises Act protections apply (emergency care or certain in-network-facility services limit patient liability)
3. 3If the provider was actually in-network but mis-loaded, correct/appeal instead of billing the patient
4. 4If patient liability is legitimate, bill the patient after appropriate notice

PR group code: who absorbs the charge

Appeal, correct, or write off PR-242?

PR-242 is collectible from the patient only when out-of-network/non-coordinated care was genuinely their choice and not legally protected. First verify the provider's network status (a mis-loaded in-network provider is an appeal, not a patient bill) and apply No Surprises Act protections for emergencies and certain facility-based care. Where patient liability is legitimate, bill the patient with advance notice.

Example

A patient on a narrow-network plan elects an out-of-network specialist without coordination, and the claim returns PR-242. If the choice was the patient's and not legally protected, the balance is theirs; if the provider was actually in-network, the directory record supports an appeal.

Prevent PR-242 going forward

• Verify network status and inform patients of out-of-network cost exposure before service
• Apply No Surprises Act protections to emergency and facility-based care
• Confirm gatekeeper/PCP coordination requirements at scheduling
• Give patients written notice and estimates for out-of-network choices

Code families most affected

• Out-of-network and narrow-network claims
• Gatekeeper/PCP-coordination plans
• Member-elected out-of-network services

Related codes

Payer notes

CARC 242 carries CO or PR depending on liability: CO-242 is provider/contractual; PR-242 shifts the balance to the patient for a knowing out-of-network choice. Confirm network status and surprise-billing protections before billing the patient.