What does denial code PR-242 mean?

PR-242 means the services were not provided by a network provider under a plan that restricts coverage to its network. The PR group code assigns the balance to the patient, though balance billing protections often limit what can actually be collected.

Can I balance bill the patient after PR-242?

Not in situations covered by balance billing protections, which include emergency services and much out-of-network care delivered at in-network facilities. In those cases the patient owes only in-network cost sharing, and the remainder is resolved with the plan rather than billed to them.

PR-242: Services were not provided by network providers

PR-242 assigns the balance to the patient, and that assignment is the part most likely to be wrong. Federal and state balance billing protections limit what an out-of-network provider may collect in emergencies and in many facility-based situations, regardless of what the group code says. Treating this as a straightforward patient balance without checking whether those protections apply creates real compliance exposure, not just an unhappy patient.

What it means: The plan restricts coverage to its network, and the provider who delivered the service is outside it.
Who pays the balance: Patient responsibility in principle - but balance billing protections frequently override that for emergencies and facility-based care.
Group code PR: Patient Responsibility - the balance transfers to the patient

Why PR-242 happens

The patient has a network-only plan and chose or was referred to an out-of-network provider.
The provider's network participation lapsed or had not begun at the date of service.
A facility was in network but an individual clinician working there was not.
An emergency was treated at the nearest facility regardless of network status.
The plan changed networks at renewal and the provider was dropped without the patient knowing.

How to fix a PR-242 denial

1
Determine whether balance billing protections apply
Emergency services and out-of-network care delivered at in-network facilities are protected in most circumstances. Where protections apply, the patient owes only in-network cost sharing and the rest is resolved with the plan.
2
Confirm the provider's actual network status for the date of service
Participation lapses and renewal changes mean the status now may differ from the status then, and the date of service is what governs the claim.
3
Check for a network gap or continuity of care exception
Plans grant in-network processing when no participating provider was reasonably available or when a patient is mid-course of treatment. Both require a request rather than arriving automatically.
4
Bill only the protected amount where protections apply
Where the patient is protected, collect the in-network cost sharing and pursue the difference through the plan's dispute process rather than from the patient.

Deadlines depend on the payer

Filing limits and appeal windows for PR-242 vary by payer and often by plan type within the same payer. Look up the specific payer to see its verified deadlines and the source document they came from.

Browse payer billing references

Preventing PR-242 denials

Verify network participation for the specific plan and product before scheduling, not just for the payer generally.
Tell patients about out-of-network status and the expected cost before elective care, in writing.
Request network gap exceptions in advance where no participating provider is available for the needed service.

PR-242 frequently asked questions

What does denial code PR-242 mean?: PR-242 means the services were not provided by a network provider under a plan that restricts coverage to its network. The PR group code assigns the balance to the patient, though balance billing protections often limit what can actually be collected.
Can I balance bill the patient after PR-242?: Not in situations covered by balance billing protections, which include emergency services and much out-of-network care delivered at in-network facilities. In those cases the patient owes only in-network cost sharing, and the remainder is resolved with the plan rather than billed to them.

Related denial codes

CO-243 CO-109 PR-204 CO-45

Last reviewed August 5, 2026.

Denial code explanations are original plain-English summaries written for reference and are not the official X12 code descriptions. Payer handling of any code varies by contract - always verify against the remittance advice and your payer agreement before adjusting a claim.