PR 242 denial code

Claim adjustment reason code 242. Often reported as PR 242 or CO 242.

Not provided by a network or PCP provider

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 Nov 11, 2026.

What 242 means

The service was provided by someone outside the plan's network or not by the patient's primary care provider.

The plan restricts who can provide covered care, and this provider is out of network or is not the patient's assigned primary care provider. It replaced an older retired code for the same kind of issue.

With PR the plan is saying the patient owes the amount under their out of network terms. With CO the provider may carry it, often due to the contract. Many of these turn out to be enrollment or assignment errors, not true out of network care.

Group codes seen with 242

On a remittance, 242 comes after a group code. These are the ones it is most often reported with:

• PR 242 (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.
• CO 242 (Contractual Obligation): The provider's side of the ledger. The reduction comes from the payer contract or a rule the provider has to follow, and the patient normally cannot be billed for it.

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 provider is not enrolled in the patient's specific plan or network product.
• The patient's HMO assigned a different primary care provider.
• The rendering provider is credentialed but was not yet loaded in the payer's network directory.
• The claim was billed under a group or location that is not in network.

What to do next

1. Check whether the rendering and billing providers are in network for the patient's specific plan.
2. Confirm the patient's assigned primary care provider for the date of service.
3. If the provider should be in network, ask provider enrollment to correct the payer's file and reprocess.
4. Ask the patient to update their PCP assignment if they now see your provider.
5. Check the group code and any out of network notice before billing the patient.

Related codes

• 243 (reason code) Not authorized by network or PCP provider
• 197 (reason code) No prior authorization on file
• 204 (reason code) Not covered under the patient's plan
• 109 (reason code) Not covered by this payer, send elsewhere