PR-204 (Non-Covered Service)
Patient Responsibility 204 — patient is responsible for amounts the plan does not cover, often when an ABN or similar notice is on file.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Denials & Appeals
- Primary sources
- 2
- Workspace handoff
- denial workbench →
Where this comes up
This is denial-workbench territory. A remit posts with a CARC/RARC, the biller decides whether to rebill, appeal, or write off, and the appeal packet has to cite the chart, the order, and the payer's own policy language. Recurring patterns trace back to an upstream workflow gap.
Full definition
What it is in practice
PR-204 typically follows GA-modifier claims that establish patient responsibility. Without the ABN, this often defaults to a CO write-off.
How it shows up in your practice
Audit the ABN file for every PR-204 to confirm the patient was properly notified.
Sources
- CMS — CARChttps://x12.org/codes/claim-adjustment-reason-codes
- CMS — ABNhttps://www.cms.gov/medicare/billing/abns
Audit PR-204 / ABN pairing in the Denial Workbench
Open denial workbench →Related terms
- Denials & AppealsPR (Patient Responsibility)An X12 adjustment group code indicating the patient owes the amount (deductible, coinsurance, copay, or non-covered service).
- Denials & AppealsGA ModifierHCPCS modifier indicating an Advance Beneficiary Notice of Non-coverage (ABN) was issued and is on file.
- Denials & AppealsABN (Advance Beneficiary Notice of Non-coverage)A standardized notice (CMS-R-131) given to Medicare fee-for-service beneficiaries before furnishing a service Medicare may not cover.
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Related across the archive
- GlossaryABN (Advance Beneficiary Notice of Non-coverage)A standardized notice (CMS-R-131) given to Medicare fee-for-service beneficiaries before furnishing a service Medicare may not cover.
- GlossaryGA ModifierHCPCS modifier indicating an Advance Beneficiary Notice of Non-coverage (ABN) was issued and is on file.
- GlossaryPR (Patient Responsibility)An X12 adjustment group code indicating the patient owes the amount (deductible, coinsurance, copay, or non-covered service).
- GlossaryAppeal LetterThe written request to a payer to reconsider a denied or partially-paid claim.
- GlossaryCARC (Claim Adjustment Reason Code)X12-maintained codes communicating why a claim or service line was paid differently than billed.
- GlossaryCO-109 (Claim Not Covered by Payer)Contractual Obligation 109 — the claim is not covered by this payer/contractor.
- GlossaryCO-16 (Claim Lacks Information)Contractual Obligation 16 — the claim or service line lacks information or has submission/billing errors.
- BillingHow to Appeal an Insurance Denial: Step-by-Step GuideClaim denied? Step-by-step appeal process with payer deadlines, denial code fixes, appeal letter template, and escalation options.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.