CARC 204PR · Patient Responsibility
This specific service, piece of equipment, or drug is excluded from the patient's current benefit plan.
- Common causes
- A plan-level exclusion for this category of service, or the patient recently changed to a plan with narrower benefits.
- Suggested fix
- Confirm the plan's covered benefits list with the payer; if excluded, the patient is typically responsible after being informed in advance.
Related Patient Responsibility codes
1The billed amount was applied to the patient's plan deductible instead of being paid by the payer.119The patient has used up the maximum benefit allowed for this service within the applicable time period, such as an annual visit limit.167The specific diagnosis code(s) on this claim aren't covered under the patient's plan.177The patient doesn't currently meet the plan's eligibility criteria for this benefit.187This amount was or should be paid from the patient's consumer-directed spending account, such as an HSA or FSA, rather than by the payer.2This portion of the claim represents the patient's coinsurance share, the percentage of the allowed amount they are responsible for under their plan.200The service date falls within a period when the patient's coverage had lapsed.201The patient is responsible for this amount under a legal set-aside arrangement, commonly seen in workers' compensation Medicare Set-Aside cases, rather than the payer.
Frequently asked questions
What does CARC 204 mean?
This specific service, piece of equipment, or drug is excluded from the patient's current benefit plan.
How do I resolve CARC 204?
Confirm the plan's covered benefits list with the payer; if excluded, the patient is typically responsible after being informed in advance.
Why does CARC 204 happen?
A plan-level exclusion for this category of service, or the patient recently changed to a plan with narrower benefits.
CARC codes maintained by X12 (x12.org). Descriptions on this site are original reference interpretations. Always verify codes with authoritative sources before making billing decisions.