PR-204: Service/drug not covered under the current plan (patient billed)
UPDATED JULY 2026 · U.S. PLANS · NOT LEGAL OR MEDICAL ADVICE
The payer says the item isn't a plan benefit and the cost is yours. For medications, the formulary-exception process is the tool; for services, the exclusion needs verifying.
PR-204 at a glance
- Code group: PR — Patient Responsibility — the payer assigns this amount to you (verify before paying).
- Who usually fixes it: You (the member).
- Worth appealing? Yes — commonly appealed.
What to do about a PR-204 denial
- Drugs: file a formulary exception with prescriber support — decisions typically come fast.
- Services: get the exclusion cited, and check your plan documents yourself.
- Appeal, and use external review if internal appeal fails — 'not covered' calls get reversed.
Best next read: Formulary / drug-not-covered denials — the full guide (with a free letter template) for this denial type.
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