CARC PR-204: Patient Responsibility — Not Covered Under Benefit Plan

PR-204 means the service, equipment, or drug isn't covered under the patient's current benefit plan — and the financial responsibility falls on the patient, not the provider. This is the critical difference from CO-204.

Official description: "This service/equipment/drug is not covered under the patient's current benefit plan."

Same description as CO-204, different group code: PR = Patient Responsibility. You can bill the patient for PR-204 denials (subject to any plan-specific restrictions).

• Out-of-network supplier. Patient's plan doesn't cover DME from out-of-network suppliers. The balance is the patient's responsibility.
• Plan explicitly lists item as patient-pay. Some plans are designed with certain DME as patient responsibility (e.g., convenience items, non-essential upgrades, lifestyle DME).
• Deductible or cost-sharing design. Some plans route non-covered services to patient responsibility rather than provider write-off.
• Waiver on file. Patient signed an ABN or equivalent waiver acknowledging the item may not be covered. Payer processes the claim with PR-204.

1. Verify patient responsibility before billing. Confirm the PR-204 is accurate by checking the plan document. Some payers miscategorize CO as PR — billing the patient for a CO denial exposes you to compliance risk.
2. Review your ABN documentation. You should have a signed ABN (for Medicare) or equivalent waiver (for commercial) obtained before delivery if you knew or suspected non-coverage. Without it, billing the patient is risky.
3. Bill the patient accurately. PR-204 means you can bill — but bill only the amount indicated, not your full charge if the plan has any pricing provisions.
4. Consider a payment plan. DME can be expensive. Offer the patient installment options and document the arrangement.
5. Check secondary coverage. Patient's secondary plan may cover what the primary denied as PR-204. Get secondary EOB before finalizing patient billing.