PR204 Denial Code

PR204 denial code – When a service/equipment/drug is not covered by the patient’s insurance plan, then those claims will be denied with the PR204 denial code. Which means patient is responsible for the service as the services-billed or drug-code-billed or an equipment-billed are not covered under the patient insurance plan.

PR204 denial code example:

Assume Patient plan covers only medical services. But provider rendered psychiatric services for the patient and billed the claim to an insurance company for reimbursement.

In this case insurance company will deny the claim with PR204 denial code. Which indicates patient plan covers only medical services, but we have billed claim with a psychiatric service and these psychiatric services are not covered as per the patient benefit plan. In this case we need to either submit to other insurance which covers the psychiatric service or we need to bill the claim to patient as members will be responsible if the services are not covered under his plan.

PR204 denial code solutions:

• Whenever we receive a PR204 denial code, the very first step is to check member’s previous service (DOS) history to see same service (procedure code and diagnosis code) billed and received a payment from the same insurance company. If yes, then we need to reach out insurance company representative and send the claim back for reprocessing stating “Previous DOS with same services, we have received a payment”.
• If not, then check eligibility of the patient to verify the member’s plan (services covered and non-covered service as per the patient benefit plan). If you are unable to view the complete details through website, then reach out an insurance company representative to verify the services covered and not covered under the patient plan.
• If the service billed is covered, then we need to reprocess the claim.
• If the services billed are not covered under the patient insurance plan, then we need to check for other active insurance which covers the services billed under the patient plan. Need to update and submit the claims to the active payer which covers the services billed.
• If no other insurance found which covers the services billed, then we need to bill the claim to patient as the services are not covered under the member’s plan.