PR-242 Denial Code: Not Provided by Network or Primary Care Provider

What is the PR-242 denial code? PR-242 is a Claim Adjustment Reason Code (CARC) meaning the services were not provided by network or primary care providers, reported under the Patient Responsibility (PR) group, the same group CMS says is typically used for deductible and copay adjustments, so the denied amount is assigned to the patient.

Undeny's Take

PR-242 tells you who the payer thinks should pay, not who legally must. Three situations flip it. First, you were in network but the payer's file did not show it for that date, location or NPI, which is a data correction, not a patient bill. Second, on Medicare Advantage, CMS says that when a contracted provider refers an enrollee to a non-contracted provider for a service the plan covers on referral, the enrollee owes only the normal cost-sharing. Third, the No Surprises Act protects patients from surprise out-of-network bills for emergency care and certain care at in-network facilities. If none of those apply and the patient knowingly chose care outside a network-only plan, PR-242 is likely legitimate. The cheapest fix is upstream: check whether the plan is an HMO before the first visit.

What PR-242 Means for Network and Gatekeeper Plans

The official X12 description is short: "Services not provided by network/primary care providers." X12 added it in 2012 as one of two replacements for code 38 ("Services not provided or authorized by designated (network/primary care) providers"), which was then deactivated. The idea was split in two: 242 for care not provided by network or primary care providers, and 243 for care not authorized by them.

The group code sets liability. CMS defines PR as an adjustment that "may be billed to the patient or insured," while the same reason under CO would generally be a contractual write-off for the provider. So PR-242 and CO-242 describe the same network problem with opposite answers on who absorbs it.

Why PR-242 Happens

• The plan covers only network care. HealthCare.gov describes an HMO as a plan that "generally won't cover out-of-network care except in an emergency," and Medicare.gov warns Medicare Advantage HMO members that care outside the network may mean paying the full cost.
• The plan requires a primary care referral. In many HMOs, HealthCare.gov notes, "if you don't get a referral first, the plan may not pay for the services."
• The payer's provider data is wrong or late. A new contract, a new location, or a rendering NPI that is not linked to your contracted group can make an in-network visit look out of network.
• An exception was not recognized. Medicare.gov lists emergency care, out-of-area urgent care and temporary out-of-area dialysis as exceptions to the network rule for Medicare Advantage HMOs.

How to Fix or Challenge a PR-242

1. Confirm your network status with the payer for the exact date of service, tax ID, NPI and location. If you were in network, ask for reprocessing or send a corrected claim instead of billing the patient.
2. Identify the plan type and check the exceptions: emergency or urgent care, and services the No Surprises Act protects.
3. For Medicare Advantage, find out whether a contracted provider referred the patient. If so, CMS's plan-directed care rule limits the enrollee to the applicable cost-sharing, and the referral record is your evidence.
4. If the patient chose out-of-network care in a plan without out-of-network benefits and was told in advance, collect the PR amount with the remittance or EOB attached.
5. If you dispute the denial, appeal with the network evidence or referral, using the payer's own appeal process, or draft it with the appeal generator.

PR-242 and Related Network or Coverage Codes

PR-243 is the sibling code: the service was not authorized by the network or primary care provider, which usually means a missing referral rather than an out-of-network clinician. PR-204 means the service is not covered under the plan at all. CO-197 means a required authorization was absent and the provider absorbs it. PR-96 is a general non-covered charge assigned to the patient, and CO-109 means the claim went to the wrong payer. For a Medicare Advantage HMO appeal, see the Humana provider appeals guide.

Frequently Asked Questions

Can I bill the patient for a PR-242 denial?

Usually, because the PR group assigns the amount to the patient. Confirm first that you were truly out of network on that date and that no protection applies, such as the No Surprises Act or Medicare Advantage plan-directed care. If the payer simply had your network status wrong, fix the data instead of sending a bill.

What is the difference between PR-242 and PR-243?

PR-242 means the service was not provided by a network or primary care provider. PR-243 means it was not authorized by one, typically a missing referral. Both replaced the old combined code 38, so read the exact number to know whether the fix is network status or a referral.

Does the No Surprises Act affect PR-242?

It can. CMS says the law protects patients from unexpected out-of-network bills for emergency room visits, non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, and air ambulance services. If the visit falls in one of those categories, check the law's cost-sharing and billing limits before collecting.

What if a network doctor referred my Medicare Advantage patient to me?

CMS treats contracted providers as agents of the Medicare Advantage plan. If a contracted provider refers an enrollee to a non-contracted provider for a service covered on referral, the enrollee is financially liable only for the applicable cost-sharing. Ask the referring office for the referral record and include it in your appeal.

Informational only, not legal, medical, or billing advice. Always verify against your current payer contract and policy.

Fix PR-242 denials automatically

Undeny drafts a network-status or referral-based appeal from your denial in seconds. Generate an appeal · Browse denial codes