Denial Code PR-96

What PR-96 means

The service isn't covered under the patient's plan, and under the PR group code the patient is responsible for the charge.

PR group code: who absorbs the charge

Why PR-96 happens

• The service is excluded from the patient's specific benefit plan
• Valid advance notice (ABN/waiver) was on file, shifting a non-covered Medicare service to patient liability
• Preventive codes (99381-99397) billed to Medicare instead of the AWV codes (G0438/G0439), which Medicare does not cover
• A service billed beyond its covered frequency, with the patient on notice

What to do when you get PR-96

1. 1Read the RARC to confirm the specific non-coverage reason
2. 2Confirm valid advance notice exists before billing the patient
3. 3If a covered code/diagnosis applies (e.g., switch to the AWV code for Medicare), submit a corrected claim instead
4. 4Bill the patient only after confirming the charge is legitimately their responsibility

Appeal, correct, or write off PR-96?

If the non-coverage is genuine and the patient was properly notified, PR-96 is not something to appeal — bill the patient. Appeal only when you believe the service should be covered (wrong determination) and can support it with documentation, or submit a corrected claim when the real problem is a miscoded service (such as a Medicare preventive visit that should have been billed as an AWV). The PR group code is the signal that the balance is collectible from the patient.

Example

A Medicare patient receives an annual physical billed as 99397. Medicare does not cover routine physicals, so it returns PR-96. The fix is usually a corrected claim billing the covered Annual Wellness Visit (G0439) instead; if the patient truly wanted the non-covered service and signed an ABN, the practice bills the patient.

Prevent PR-96 going forward

• Use AWV codes (G0438/G0439), not preventive E/M codes, for Medicare wellness visits
• Collect a signed ABN before any likely-non-covered Medicare service
• Educate front-desk staff on plan exclusions during scheduling
• Verify benefits for elective/non-standard services before the visit

Code families most affected

• Preventive medicine E/M (99381-99397) vs. Medicare AWV (G0438/G0439)
  G0438G0439
• Plan-excluded services
• Frequency-limited screenings

Related codes

Payer notes

PR-96 puts the balance on the patient. For a Medicare service that is usually covered but denied for necessity, you may bill the patient only with a valid ABN on file — without it, the charge generally falls under CO-96 (provider write-off). Services Medicare never covers (statutory exclusions) are the patient's responsibility regardless, though a voluntary ABN is recommended.