What is the denial code for a non-covered service?

The most common are PR-96 and PR-204, which mean the service is not a benefit under the patient's plan and move the balance to the patient. CO-96 is the same finding with the balance assigned to the provider. More specific codes include PR-49 for routine exams, CO-167 for excluded diagnoses, and PR-51 for pre-existing condition exclusions.

Can I bill the patient for a non-covered service?

When the group code is PR, usually yes - provided the patient was informed beforehand wherever the plan or your contract requires it. Medicare requires a valid Advance Beneficiary Notice signed before the service. When the group code is CO, the provider absorbs the balance and cannot bill the patient.

Non-covered service denial codes

Non-covered denials are benefit decisions, not judgments about the care, and the group code does most of the work in deciding who pays. PR-96 and PR-204 say the service falls outside the patient's plan and move the balance to the patient. CO-96 is the same non-covered finding with the balance assigned to the provider. PR-49 applies when a routine or screening service is not part of the plan's benefits, CO-167 when the plan excludes the diagnosis itself, and PR-51 when a pre-existing condition exclusion or waiting period was applied.

Also described as: not a covered benefit; excluded service; plan exclusion; routine exam not covered; pre-existing condition.

The 6 codes and what separates them

CO-96 - Non-covered charge the provider absorbs
The service is not covered, and the contractual group code leaves the balance with the provider - typically because the network contract bars billing the member for it.
Who pays: Provider
PR-96 - Non-covered charges
The service is not a benefit under the plan and the balance moves to the patient; the remark codes name the basis.
Who pays: Patient, with notice
PR-204 - Service not covered under the patient's current benefit plan
The service is outside the benefits of this patient's specific plan, even if other plans from the same payer cover it.
Who pays: Patient, with notice
PR-49 - A routine or screening exam the plan does not cover
The service was reported as routine, preventive, or screening, and the plan does not include that benefit.
Who pays: Patient, with notice
CO-167 - The diagnosis is not covered by this plan
The plan excludes the diagnosis itself, so services treating that condition are not payable however necessary they are.
Who pays: Provider
PR-51 - A pre-existing condition exclusion was applied
The payer applied a pre-existing condition exclusion or waiting period. Most medical plans can no longer impose these under the Affordable Care Act, so check the plan type before accepting it.
Who pays: Disputed - challenge it

How to tell which one you have

Before accepting any of these, confirm the payer adjudicated against the right plan - a stale eligibility record is a common reason a covered service comes back as non-covered. Then read the group code. PR means the balance can move to the patient, but many network contracts, and Medicare, require that the patient was told in advance and agreed in writing; for Medicare that means a valid Advance Beneficiary Notice. CO means the provider absorbs it. A PR-49 often comes from a plan with no routine-exam benefit at all - traditional Medicare does not cover routine physicals beyond the Welcome to Medicare visit and the annual wellness visit - or from a preventive service billed outside the plan's age or frequency limits.

Frequently asked questions

What is the denial code for a non-covered service?: The most common are PR-96 and PR-204, which mean the service is not a benefit under the patient's plan and move the balance to the patient. CO-96 is the same finding with the balance assigned to the provider. More specific codes include PR-49 for routine exams, CO-167 for excluded diagnoses, and PR-51 for pre-existing condition exclusions.
Can I bill the patient for a non-covered service?: When the group code is PR, usually yes - provided the patient was informed beforehand wherever the plan or your contract requires it. Medicare requires a valid Advance Beneficiary Notice signed before the service. When the group code is CO, the provider absorbs the balance and cannot bill the patient.

Other denial reasons

Out of network No prior authorization Not medically necessary Bundled or not paid separately Coding mismatch or invalid code Patient not eligible or coverage ended Another payer is responsible Missing information, duplicate, or late filing Provider not eligible or not credentialed Benefit or unit limit reached Deductible, coinsurance, or copay Paid less than billed

Every denial code in one table

Last reviewed October 3, 2026.

These are original plain-English summaries written for reference, 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.