PR-204: not covered under the current plan.

What X12 says CARC 204 means

This service/equipment/drug is not covered under the patient's current benefit plan

CARC 204 · Start 02/28/2007.

In plain terms: The patient's current plan does not cover this service, equipment or drug.

What it means on a remittance

The X12 wording names the service, equipment or drug and ties the denial to "the patient's current benefit plan". That points at the plan the patient has now, not at the billing or coding on the claim. The group code on the line tells you who the payer says owes the amount: PR is Patient Responsibility.

Typical causes

• The plan excludes the service, item or drug as a benefit category.
• The claim went to a plan other than the one in force on the date of service, for example after a plan change or a coverage end date.
• A benefit limit or rider the patient does not have, so the plan treats the service as outside the benefit.
• The wrong payer was billed first, when another plan is primary.

These are common billing patterns, not a diagnosis of your claim. The remittance and the payer's policy decide.

What to check

1. Re-run eligibility for the date of service and compare the plan name and ID with the claim.
2. Read the plan's summary of benefits and coverage or the payer policy for the service named on the line.
3. Check the remark code on the same line. N130 points you to the plan benefit documents.
4. Confirm the order of payers if the patient has more than one plan.

Correct, resubmit or appeal

If the plan or date was wrong, submit the claim to the right payer or a corrected claim as that payer requires. If the plan truly excludes the service, the denial is usually final on its face, but the group code and your payer contract or the patient's plan documents decide who owes the amount, so read them before you bill the patient. If you believe the service is a covered benefit, ask the payer for review with the plan language you rely on.

Medicare dates that apply

A Medicare redetermination request must be filed within 120 calendar days from the date a party receives the notice of the initial determination; receipt is presumed 5 calendar days after the notice date unless there is evidence to the contrary (42 CFR 405.942(a)), and a late request can be considered for good cause (405.942(b)). Other payers set their own appeal windows in the contract or plan documents, so read the notice for the date. The tool above runs the date math.

Related codes

X12 does not publish a table that pairs each code with remark codes; the payer picks the remark code and prints it beside the CARC on the same remittance line. These X12 remark codes carry wording that speaks to this topic:

• N130 — Consult plan benefit documents/guidelines for information about restrictions for this service.

Other codes: CARC 24 (charges covered under a capitation agreement or managed care plan) and CARC 109 (claim not covered by this payer).

Worked example (hypothetical)

A claim is denied PR-204 for a service the patient's plan lists as an exclusion in its summary of benefits. The biller confirms the plan was active on the date of service, finds the exclusion, records the denial, and sends the patient an explanation based on the plan document rather than billing automatically.

Sources

• X12: Claim Adjustment Reason Codes — code text, usage notes and dates (list dated 10/30/2026, retrieved 2026-11-02)
• X12: Remittance Advice Remark Codes — remark code text (retrieved 2026-11-02)
• 42 CFR 405.942 — eCFR, current through 2026-10-29 (retrieved 2026-11-02)

Code descriptions are X12 copyrighted material, quoted here only for the codes on this page and linked to the owner. For the full lists, use X12. The X12 text and the Medicare rule above were read from these pages on November 2, 2026. Causes, checks and examples are general billing practice written for this page, not X12 content. Payers revise code lists, contracts and policies, so confirm anything that affects a claim or a deadline with the payer.