PR-202 Denials Explained: How to Identify, Appeal, and Prevent Them

Denial codes can significantly impact healthcare revenue cycle teams, and PR-202 is among the most common yet misunderstood issues. This denial is tied to non-covered personal comfort services, often leaving patients responsible for expenses that are not part of their covered benefits. For RCM teams, understanding PR-202 is critical to minimizing revenue leakage, maintaining cash flow, and improving operational efficiency.

In this blog, we’ll break down what PR-202 denials mean, how they differ from similar codes, and actionable strategies to appeal and prevent these denials effectively.

What Is a PR-202 Denial?

The PR-202 denial code refers to services deemed as non-covered personal comfort or convenience items. The prefix "PR" indicates patient responsibility, meaning the financial burden falls on the patient rather than the payer. These items are excluded from coverage because they are not considered medically necessary or directly related to the patient’s treatment.

It’s important for RCM teams to recognize PR-202 denials early to ensure patients are properly informed and prevent unnecessary disputes or delays in collections.

Comparison: PR-202 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-202	Patient Responsibility	Non-covered personal comfort or convenience services	Patient
PR-96	Patient Responsibility	Non-covered service not medically necessary	Patient
CO-50	Contractual Obligation	Non-covered service under payer contract	Provider

While PR-202 and PR-96 both fall under patient responsibility, PR-202 specifically applies to personal comfort items, whereas PR-96 involves services deemed clinically unnecessary. CO-50 differs entirely, as it reflects payer policies excluding specific services, making the provider financially accountable.

Common Causes of PR-202 Denials

1. Incorrect Service Classification: Services incorrectly categorized as medically necessary instead of personal comfort items.
2. Lack of Documentation: Insufficient clinical notes or records supporting the necessity of the service.
3. Patient Miscommunication: Patients unaware that specific services or items are excluded from their coverage.
4. Billing Errors: Incorrect use of codes or modifiers when submitting claims.
5. Payer Policies: Variation in payer contracts leading to inconsistent denial reasons.

Impact on Revenue Cycle Teams

PR-202 denials create significant financial and operational challenges for healthcare organizations:

Financial Impact:
- Revenue loss from claims requiring rework or write-offs.
- Increased accounts receivable days, straining cash flow.
- Higher operational costs due to prolonged denial management processes.

Operational Impact:
- Staff resources diverted from other critical RCM tasks.
- Need for advanced payer policy knowledge and clinical documentation expertise.
- Coordination challenges between teams to address denial trends effectively.

To mitigate these impacts, healthcare organizations must adopt robust solutions like CombineHealth.ai's AI-powered denial management tools. Adam (AI Denial Manager) automates denial tracking, resolution, and reporting, reducing manual errors and improving efficiency.

Steps To Appeal a PR-202 Denial

Step 1: Review the Denial Notice
Carefully examine the explanation of benefits (EOB) or payer correspondence to confirm the denial reason and code.

Step 2: Gather Documentation
Compile all necessary clinical records, physician notes, and itemized bills to substantiate the service’s validity.

Step 3: Verify Eligibility
Cross-check patient insurance coverage against payer policies to confirm whether the denial aligns with exclusions.

Step 4: Prepare Appeal Letter
Draft a clear and concise appeal letter, including supporting documentation and references to payer guidelines.

Step 5: Submit Within Deadline
Ensure timely submission of the appeal, adhering to the payer’s specified deadlines.

Step 6: Track and Follow Up
Monitor the status of the appeal and follow up with the payer if additional information or action is required.

How To Prevent PR-202 Denials

Front-End Prevention

• Eligibility Verification: Verify patient benefits during registration to identify excluded services.
• Patient Communication: Educate patients upfront about personal comfort items not covered by their plan.

Billing Best Practices

• Accurate Coding: Use precise codes and modifiers to classify services correctly.
• Pre-Authorization Checks: Confirm coverage for services that may fall into gray areas.

Technology Solutions

• Automated Tools: Implement CombineHealth.ai’s Adam for real-time denial tracking and Rachel for streamlined appeals.
• Claim Scrubbing: Utilize AI-driven claim scrubbing to catch errors before submission.

CombineHealth.ai’s platform integrates eligibility verification and claim scrubbing tools to proactively prevent PR-202 denials. When denials do occur, Rachel simplifies appeal workflows, reducing turnaround times and improving success rates.

FAQs

Q1: What does PR-202 mean in medical billing?
PR-202 refers to denied claims for non-covered personal comfort or convenience services, with financial responsibility falling on the patient.

Q2: Can PR-202 denials be appealed?
Yes, PR-202 denials can be appealed with proper documentation and adherence to payer guidelines.

Q3: How long do I have to appeal?
Appeal timelines vary by payer but typically range from 30 to 90 days. Always check the denial notice for specific deadlines.

Q4: How can I prevent these denials?
Prevent PR-202 denials with real-time eligibility checks, precise coding, and automated claim scrubbing tools. See our complete guide on denial prevention.