PR-96 Denial Code Explained

PR-27 is a medical billing denial code that indicates expenses were incurred after the patient's insurance coverage terminated. This denial commonly occurs when services are provided after the policy's effective coverage period has ended.

What Does PR-27 Mean?

The PR-27 denial code means the insurance payer determined the patient's coverage was no longer active on the date of service.

This denial is often related to terminated policies, eligibility issues, or outdated insurance information.

Common Reasons for PR-96

• Service not covered by the patient's benefit plan

• Plan exclusion applies

• Experimental or investigational service

• Coverage limitations

• Non-covered procedure

• Benefit restrictions

How To Fix PR-96

Review the patient's explanation of benefits and verify whether the service is excluded under the benefit plan. Confirm coverage before billing the patient and determine whether additional documentation or an appeal is appropriate.

If the denial was issued incorrectly, contact the payer and submit supporting documentation.

Frequently Asked Questions

Can the patient be billed for PR-96?

In many cases, yes. Providers should verify payer rules and patient responsibility before billing.

Is PR-96 the same as CO-96?

No. PR-96 assigns financial responsibility to the patient, while CO-96 is generally a contractual adjustment assigned to the provider.

Can prior authorization prevent a PR-96 denial?

Not always. A prior authorization does not guarantee coverage if the patient's benefit plan excludes the service.

How can providers prevent PR-96 denials?

Verify benefits and coverage before services are provided and discuss potential financial responsibility with the patient.

Related Denial Codes

You may also encounter:

• PR-1 — Deductible amount

• PR-2 — Coinsurance amount

• PR-3 — Copayment amount

• CO-96 — Non-covered charge

Quick Summary

PR-96 indicates the payer considers the service non-covered and assigns the remaining balance to patient responsibility. Most denials are caused by benefit exclusions, non-covered services, or plan limitations.