PRPatient Responsibility · CARC Code 96
PR-96

Non-Covered Charges — Patient Is Responsible

PR-96 means the service is excluded from the patient's benefit plan and the patient is financially responsible — but only if you gave proper advance notice before rendering the service. For Medicare patients, that means an ABN. Without notice, you write it off.

Updated August 2026·Group: PR (patient responsibility)·Critical: advance notice required before billing patient
Notice firstABN (Medicare) or Financial Notice Required Before Service
PR vs COPR-96 = Bill Patient; CO-96 = Provider Write-Off
Verify firstConfirm Non-Coverage Before Service — Not After
EOB amountBill the Exact PR-96 Dollar Amount — Never More
PR-96 in plain English

PR-96 means this service is not covered by the patient's plan and the patient owes the amount. The PR group code authorizes patient billing. But there's a critical condition: you can only collect from the patient if you told them before the service that it might not be covered and they acknowledged the financial responsibility. For Medicare patients, that notice is an ABN. Without it, you absorb the write-off even though the code says PR.

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Check the group code: PR-96 ≠ CO-96

CO-96 (same CARC number, different group code) means the provider absorbs the write-off — patient billing is prohibited. PR-96 means patient billing is authorized. Before sending any patient statement for a CARC 96 adjustment, verify the group code on the EOB is PR, not CO. Billing the patient for a CO-96 denial is a balance billing violation.

Advance Notice Requirements

When you can bill the patient — and when you can't

✓ You CAN bill the patient when:

• Medicare: You issued a valid ABN (CMS-R-131) before the service, the patient signed it, and they chose to proceed knowing they might pay.

• Commercial: You gave the patient a written financial responsibility notice before service, they signed it, and the service was rendered after that acknowledgment.

• The EOB group code is PR (not CO) for the 96 adjustment.

✗ You CANNOT bill the patient when:

• Medicare: No ABN was issued before the service (even if the patient would have signed one).

• The EOB group code is CO-96 (not PR-96) — provider write-off, patient billing prohibited.

• You failed to verify non-coverage before service and didn't disclose the risk to the patient.

• The service was an emergency — different rules apply for emergency non-coverage.

Step-by-Step

How to handle PR-96 — from pre-service verification to patient billing

  1. Verify non-coverage before the service is rendered
    Run eligibility and check the specific service against the patient's benefit exclusions. If the eligibility response doesn't clearly show the exclusion, call the payer's provider services line and ask specifically whether CPT [X] is covered for this patient. Document the verification with the payer rep name, date, and outcome. Non-coverage confirmed before service = valid basis for patient notice.
  2. Issue the appropriate advance notice and obtain patient signature
    Medicare: Issue the ABN (CMS-R-131). Give it to the patient with enough time to make a genuine decision — not as they're being wheeled into a procedure room. The patient chooses: Option 1 (receive service, may pay if denied) or Option 2 (decline service). Commercial: Give a written financial responsibility notice showing the service, why it may not be covered, estimated cost, and asking for signature. File the signed notice in the patient's record.
  3. Submit the claim with the ABN modifier if applicable
    For Medicare ABN situations where you believe coverage is uncertain (not certain denial), use modifier GA (ABN on file, patient agrees to pay if Medicare denies) or GX (voluntary ABN — patient chose to receive a non-covered service). These modifiers signal to Medicare that the patient has been notified. Without the correct modifier, Medicare may process the claim differently than intended.
  4. Confirm PR-96 (not CO-96) on the EOB before billing the patient
    When the EOB arrives, verify the group code is PR. If it's CO, do not bill the patient regardless of your ABN. Some services are contractually non-billable even with patient agreement. If you believe the payer applied CO-96 incorrectly where PR-96 should apply, call the payer to dispute the group code assignment before adjusting in your billing system.
  5. Bill the patient the exact PR-96 amount with a clear non-coverage explanation
    Send the patient statement for the exact PR-96 dollar amount from the EOB. Include a plain-language explanation: "Insurance did not cover this service because [reason]. You agreed to be responsible for this amount before the service was provided." Attach a copy of the EOB. Patients who understand why they're billed pay faster and dispute less.

Frequently Asked Questions: PR-96

PR-96 means the charge is non-covered under the patient's plan and the patient is responsible for the amount. The PR group code authorizes patient billing, but only if proper advance notice (ABN for Medicare, financial notice for commercial) was provided before the service.
PR-96 = patient pays. CO-96 = provider write-off, patient billing prohibited. Same CARC number (96 = non-covered charge), completely different financial outcome based on the group code. Always check whether the group code is PR or CO before billing any patient for a 96 denial.
An ABN (Advance Beneficiary Notice of Non-coverage) is a Medicare-specific form (CMS-R-131) that must be given to Medicare patients before providing a service you believe Medicare will deny as non-covered or not medically necessary. Without a valid ABN signed by the patient, you cannot bill a Medicare patient for a PR-96 denial — you must write it off regardless of the group code.
No. For Medicare patients, the ABN is required before billing for any denied service. Without it, the provider absorbs the write-off even if the EOB shows PR-96. The ABN is the legal mechanism for transferring non-covered service liability to the Medicare patient.
Both mean the patient owes for a non-covered service. PR-96 (CARC 96) typically identifies a specific charge that is non-covered — a specific exclusion under the plan. PR-204 (CARC 204) indicates the service type is not in the benefit package at all. In practice, the billing response is the same for both: verify advance notice was given, confirm PR group code, bill the exact EOB amount.
Related Codes

Codes related to PR-96

CO-96
Non-covered charge where provider absorbs — cannot bill patient
PR-204
Service not covered by current plan — patient pays with notice
CO-50
Medical necessity denial — different from non-coverage, appealable
All codes →
Full CARC & RARC denial code reference

Getting PR-96 without having issued an ABN? You're writing off collectable revenue.

Every non-covered service rendered without proper advance notice is a preventable write-off. A free RCM audit identifies which non-covered services in your charge mix need an ABN or financial notice workflow, and builds the pre-service verification process that shifts those balances to the patient before service begins.

Get a Free RCM Audit → Denial Management Guide