PR-96: Non covered service

What PR-96 means

The plan does not cover this service and the balance belongs to the patient.

What it usually means in a chiropractic office

Often overlaps with plan exclusions on therapies or supplies. The practice question is not the code, it is whether the patient knew before the visit that the service was not covered.

How to work it

1. Confirm the exclusion against the plan document or an eligibility check.
2. Bill the patient, ideally against a financial policy they signed at intake.
3. Add the exclusion to the patient insurance notes so the next visit is priced correctly up front.

What this looks like in practice

A plan excludes mechanical traction. The patient gets it anyway as part of a visit, the line denies PR-96, and the balance lands on the patient. Whether that balance is collectible with goodwill intact depends entirely on whether anyone told the patient before the visit that the service was not covered.

How to stop it from happening again

• ✓Record service level exclusions from eligibility results on the patient profile
• ✓Price excluded services to the patient up front under a signed financial policy
• ✓For Medicare excluded services, use the proper notice so patient billing is clean

General information for billing teams, not legal or payer specific advice. CARC definitions belong to X12; payer policies vary and control. Verify against the payer contract before acting on any individual claim.