PR 49 denial code

Claim adjustment reason code 49. Often reported as PR 49 or CO 49.

Routine or preventive exam not covered

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 49 means

The plan does not cover the service because it was a routine exam, screening or a service done along with one.

The payer treated the service as routine or preventive care that this plan does not cover, or as a service done during such a visit. It can also mean a screening was billed when the plan expects a different preventive benefit or code.

Coverage of preventive care depends heavily on the plan, the diagnosis and the codes used. Check the remittance for a service line policy reference, which points to the payer's specific rule.

Group codes seen with 49

On a remittance, 49 comes after a group code. These are the ones it is most often reported with:

• PR 49 (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 49 (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 patient's plan does not cover routine physicals or certain screenings.
• A problem oriented service was coded with only a routine exam diagnosis.
• The screening was billed more often than the plan's preventive benefit allows.
• A service was done during a preventive visit and the payer bundled or excluded it.

What to do next

1. Check the patient's preventive benefits and frequency limits.
2. Review whether a separate problem oriented service was documented and coded correctly.
3. Send a corrected claim if the diagnosis or code did not match the visit.
4. Confirm the group code and any patient notice before moving the balance to the patient.

Related codes

• 50 (reason code) Not medically necessary per the payer
• 11 (reason code) Diagnosis does not support the procedure
• 1 (reason code) Amount applied to the deductible