PR-96: Non-Covered Charges (Patient Responsibility)
Non-covered charge(s). The patient is responsible for these charges because the service is not covered under their benefit plan.
Why Claims Get Denied with PR-96
Denial code PR-96 is triggered when non-covered charge(s). the patient is responsible for these charges because the service is not covered under their benefit plan. Understanding the root causes helps prevent future denials and strengthens your appeal when one occurs.
Service explicitly excluded from the patient's benefit plan
Patient was informed of non-coverage via ABN or financial responsibility form
Elective or cosmetic service not covered by insurance
Service exceeds plan benefit limits and patient is responsible for the excess
How to Appeal PR-96
Verify that the service is truly non-covered by reviewing the patient's benefit plan. If the service should be covered, appeal with benefit plan documentation. If the patient signed an ABN or financial responsibility form, the patient is responsible for the charges. If no ABN was obtained for Medicare, the provider may be liable.
Documentation Required for Appeal
A successful appeal of PR-96 requires thorough documentation. Gather these items before drafting your appeal letter:
Signed ABN or financial responsibility form
Patient's benefit plan showing non-covered services
Eligibility verification detailing benefit exclusions
Patient cost estimate acknowledgment
How to Prevent PR-96 Denials
Verify coverage before rendering services. Obtain signed ABNs for Medicare services that may not be covered. Provide cost estimates and financial responsibility forms for potentially non-covered services. Inform patients of plan exclusions before treatment.
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