PR-96: Non-covered charge, patient responsibility

What it means

PR-96 means the charge is non-covered and the payer is placing that balance on the patient. It is usually paired with a RARC explaining why the service is not covered. The key difference from CO-96 is the responsibility party, which here is the patient.

Mechanically this fires when a service falls outside covered benefits but plan rules or a signed patient agreement make the member responsible. Whether you can actually bill the patient often depends on notice requirements and any waiver the patient signed acknowledging non-covered services.

Why it happens in behavioral health

In behavioral health PR-96 appears on services a plan excludes but that the patient chose to receive, such as certain wellness, experiential, or ancillary offerings not covered by the behavioral benefit. Programs that offer enhanced services beyond the covered core often see these fall to the patient.

Because SUD and mental health clients can be financially vulnerable, PR-96 balances require careful handling. Confirm the service was truly non-covered, that the patient was informed in advance, and that any required acknowledgment was signed before billing the balance to the patient.

How to fix it

• Read the accompanying RARC to confirm the specific reason the service is non-covered.
• Verify the patient was notified in advance and signed any required non-covered acknowledgment.
• If notice requirements were met, bill the patient for the non-covered balance.
• If the denial is a billing error rather than a true exclusion, correct the claim and resubmit.

How to prevent it

• Verify covered benefits at intake and identify services that will fall to the patient.
• Obtain signed advance acknowledgment before delivering non-covered services.
• Give patients written cost estimates for any elective non-covered offerings.

Related denial codes