Denial code PR-204

What does Denial code PR-204 mean on a medical bill?

PR-204 means the service, drug, or item is not part of what your plan covers at all, and the amount is being pointed at you. That is different from a claim stopped over paperwork: nothing was missing, the benefit simply is not there. Two things are still worth checking before you accept it. First, whether the code billed actually describes what you received. Second, whether your plan has an exception path for the item, which is common for a brand-name drug that has a covered alternative.

What should I watch out for with Denial code PR-204?

• Ask the billing office to read you the code that was billed and confirm it matches what you got
• Ask your plan whether an exception or a formulary review exists for this item, and how to request one
• Ask the provider for their self-pay or discounted rate when the item really does sit outside your benefits