PR-96: Non-Covered Charge (Patient Responsibility)
PR (Patient Responsibility)What is PR-96?
PR-96 is a Patient Responsibility code indicating the charge is the patient's responsibility because the service is not covered under their plan. Unlike CO-50 (where the provider absorbs the cost), PR-96 means the patient can be billed for the full non-covered amount.
Why Does PR-96 Occur?
- Service excluded from the plan and the patient signed a waiver accepting financial responsibility.
- ABN (Advance Beneficiary Notice) was obtained for Medicare patients, transferring liability to the patient for non-covered services.
- Elective or cosmetic service not covered by the plan.
How to Fix PR-96 Denials
- Confirm the patient signed a valid ABN (Medicare) or financial responsibility waiver (commercial) before the service was rendered.
- If a waiver is on file, bill the patient for the non-covered amount with a clear explanation of why the service was not covered.
- If no waiver was obtained, the provider may not be able to bill the patient. Check payer and state regulations.
- For future non-covered services, always obtain a signed ABN or waiver before rendering the service.
PR-96 by Payer
| Payer | Common RARC | Appeal Deadline | Notes |
|---|---|---|---|
| UnitedHealthcare | N/A | 60 days from remittance | UHC requires advance written notice to the patient for non-covered services. |
| Anthem | N/A | 365 days from denial notice | Anthem plan documents define which services can be balance-billed to the patient. |
| Aetna | N/A | 180 days from denial | Aetna requires documentation that the patient was informed before the service. |
| Cigna | N/A | 180 days from denial | Check Cigna's provider agreement for balance billing rules on non-covered services. |
| Medicare | N/A | 120 days (redetermination at MAC) | A valid ABN (CMS-R-131) must be on file to bill the patient. Without it, the provider absorbs the cost. |
Related CARC Codes
If you are seeing PR-96, check these related codes: CO-50 (non-covered service), PR-1 (deductible), CO-167 (diagnosis not covered).
Common Questions About PR-96
What is an ABN?
An Advance Beneficiary Notice (ABN) is a form Medicare requires providers to give patients before rendering a service that Medicare may not cover. The patient signs it to acknowledge they may be responsible for the full cost.
Can I bill the patient without an ABN?
For Medicare patients, no. Without a signed ABN, the provider cannot bill the patient for non-covered services and must absorb the cost. Commercial plan rules vary by payer and state.
Altair catches PR-96 denials before submission with ABN tracking and compliance. See how pre-submit claim scoring works.