PR-96 Denials Explained: How to Identify, Appeal, and Prevent Them

Denials in medical billing can disrupt cash flow and create operational bottlenecks, and PR-96 is one of the most common challenges faced by revenue cycle management (RCM) teams. PR-96 denials occur when a payer determines that specific charges are not covered under the patient’s insurance plan, leaving the financial responsibility with the patient.

In this blog, we’ll demystify PR-96 denials, explore their causes and impact on RCM teams, and provide actionable steps to appeal and prevent them. With the right strategies and tools, such as those offered by CombineHealth.ai, healthcare organizations can reduce denial rates and maximize revenue.

What Is a PR-96 Denial?

The PR-96 denial code is issued by payers when a charge is deemed a “non-covered service” under the patient’s insurance policy. The prefix “PR” indicates that the responsibility for payment lies with the patient, not the provider or payer. Denials with this code are often accompanied by a Remark Code for additional clarity on why the charges were denied.

Prefix Definitions

• PR (Patient Responsibility): The patient is responsible for paying the denied amount.
• CO (Contractual Obligation): The provider cannot bill the patient; the adjustment is based on contract terms.
• OA (Other Adjustment): Adjustments unrelated to patient responsibility or contractual obligations.

For PR-96 denials, the patient must settle the denied charges unless an error was made in the claim submission or payer adjudication.

Comparison: PR-96 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-96	Patient Responsibility	Non-covered charge(s). Requires at least one Remark Code for clarification.	Patient
CO-97	Contractual Obligation	Charges are not payable per the payer-provider contract.	Provider
OA-109	Other Adjustment	Claim/service not covered because it is not deemed a medical necessity.	Patient or Provider

While PR-96 indicates the patient’s responsibility, CO-97 and OA-109 reflect obligations or denials based on contractual terms or medical necessity. Understanding these distinctions is crucial for addressing the correct root cause and resolution path.

Common Causes of PR-96 Denials

1. Excluded Services or Procedures: The patient’s insurance policy explicitly excludes certain services, such as cosmetic procedures or experimental treatments.
2. Invalid Codes or Documentation Gaps: Errors in coding or incomplete supporting documentation can trigger non-coverage determinations.
3. Out-of-Network Providers: Services rendered by out-of-network providers may not be covered under the patient’s plan.
4. Policy Limitations: Services exceeding policy limits, such as annual visit caps, are flagged as non-covered.
5. Coordination of Benefits (COB) Issues: Failure to appropriately coordinate primary and secondary payer benefits can result in denials.

Impact on Revenue Cycle Teams

PR-96 denials pose financial and operational challenges for healthcare organizations, potentially leading to revenue leakage and increased denials management efforts.

Financial Impact

• Loss of revenue due to uncollectible patient responsibility amounts.
• Prolonged accounts receivable cycles, delaying payments.
• Increased write-offs for unappealed or unresolved denials.
• Higher administrative costs associated with rework and follow-up.

Operational Impact

• Staff resources redirected toward denial resolution, reducing efficiency in other areas.
• Necessity for in-depth knowledge of payer-specific policies and patient benefits.
• Greater coordination required between billing, coding, and clinical teams to address and prevent future denials.
• Increased need for reporting and analytics to identify denial trends and root causes.

Advanced denial management tools, such as CombineHealth.ai's Adam (AI Denial Manager), can help RCM teams mitigate these impacts by automating tracking, resolution, and prevention efforts.

Steps To Appeal a PR-96 Denial

Appealing PR-96 denials requires a proactive, organized approach to ensure timely and effective resolution.

Step 1: Review the Denial Notice
Carefully analyze the Explanation of Benefits (EOB) or Remittance Advice (RA) to understand the specific reason for the denial and any accompanying Remark Codes.

Step 2: Gather Documentation
Collect all necessary supporting documents, including medical records, prior authorization approvals, and proof of eligibility or coverage.

Step 3: Verify Eligibility
Confirm the patient’s insurance coverage and benefits to identify any discrepancies or errors in the denial.

Step 4: Prepare Appeal Letter
Draft a formal appeal letter addressing the payer’s denial reason. Include relevant documentation and a clear explanation for why the claim should be reconsidered.

Step 5: Submit Within Deadline
Ensure the appeal is submitted within the payer’s specified timeframe. Late appeals are often automatically denied.

Step 6: Track and Follow Up
Monitor the status of the appeal and follow up with the payer to ensure timely resolution.

How To Prevent PR-96 Denials

Preventing PR-96 denials requires a combination of front-end processes, billing best practices, and technology solutions.

Front-End Prevention

• Eligibility Verification: Verify patient coverage and benefits at the time of scheduling and again before the date of service.
• Authorization Management: Confirm prior authorizations are in place for services requiring payer approval.

Billing Best Practices

• Accurate Coding: Use precise, up-to-date CPT, ICD-10, and HCPCS codes to avoid billing errors.
• Thorough Documentation: Ensure clinical documentation supports the medical necessity and coverage of services.

Technology Solutions

• Automated Claim Scrubbing: Use tools like CombineHealth.ai's Adam to identify errors or omissions before claims are submitted.
• Real-Time Data Analytics: Leverage insights into denial trends to address systemic issues and improve processes.

CombineHealth.ai’s intelligent RCM solutions, including Rachel (AI Appeals Manager), streamline eligibility checks, claim scrubbing, and denial appeals. By automating these processes, healthcare organizations can significantly reduce denial rates and improve cash flow.

FAQs

Q1: What does PR-96 mean in medical billing?
PR-96 is a denial code indicating that charges are not covered under the patient’s insurance policy, making the patient financially responsible.

Q2: Can PR-96 denials be appealed?
Yes, PR-96 denials can be appealed if there is evidence of payer error, incorrect coding, or incomplete adjudication.

Q3: How long do I have to appeal?
Appeal timelines vary by payer but typically range from 30 to 90 days. Confirm specific deadlines with the payer.

Q4: How can I prevent these denials?
Prevent PR-96 denials with robust eligibility verification, accurate coding, and automated claim scrubbing. See our complete guide on denial prevention.