PR 200 denial code
Claim adjustment reason code 200. Often reported as PR 200.
Service during a gap in coverage
Unofficial reference. This is our own plain-English explanation, not the official code text. Payer rules differ. Verify with the payer and the official X12 code list. AlphaPrefix is not affiliated with X12, CMS or any payer. Data last updated .
What 200 means
The patient's coverage had lapsed on the date of service, so the payer did not cover the expenses.
The patient was enrolled with this payer at some point, but not on this date. The coverage was paused, terminated or not yet reinstated when the service happened.
With group code PR the balance usually moves to the patient's responsibility, unless other coverage existed or the lapse is later reversed, for example after a late premium payment.
Group codes seen with 200
On a remittance, 200 comes after a group code. These are the ones it is most often reported with:
- PR 200 (Patient Responsibility): The amount is assigned to the patient. Deductibles, coinsurance and copays are the everyday examples. Whether you can collect it still depends on your contract and the patient's plan.
The payer chooses the group code for each adjustment, so the same reason code can appear with another group code on your remittance. Read the two together. More about group codes.
Common causes
- The patient's premium was not paid and coverage was suspended for that period.
- Coverage ended and restarted later, leaving a gap that includes the service date.
- Eligibility was not checked on the day of service.
What to do next
- Verify eligibility for the exact date of service with the payer.
- Ask the patient whether they had other coverage during the gap and bill that plan if so.
- Hold the claim and rebill if the patient expects coverage to be reinstated retroactively.
- Follow your patient balance policy once the lapse is confirmed on the remittance.
Related codes
- 27 (reason code) Service after coverage ended
- 238 (reason code) Ineligible period reduction (patient)
- 239 (reason code) Claim spans covered and uncovered dates
- 109 (reason code) Not covered by this payer, send elsewhere
Source
Official wording: X12 Claim Adjustment Reason Codes list. The explanation on this page is our own plain-English wording, not the X12 text.
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