PR-96 on a dental EOB: non-covered services the patient owes
PR-96: Non-covered charge. What it means on a dental claim, why dental offices get it, what to do, and whether the patient owes it.
By Dr. Salem Sayegh, general dentist, Glendora, California ·
The short answer: PR-96 means the plan does not cover the service, and the amount is the patient’s responsibility. On dental claims it is common for cosmetic work, implants or orthodontics on plans without that coverage, and some adjunctive procedures. Bill the patient, ideally after telling them before treatment. If the same service comes back as CO-96, the office absorbs it, which is worth questioning.
| Code | PR-96 (adjustment reason code) |
|---|---|
| Group | PR, patient responsibility: the patient owes it |
| Meaning | The plan does not cover this service |
| Is it a denial? | Yes, of coverage |
| Bill the patient? | Yes |
| Worth a second look when | It comes back as CO-96 instead, or on a service the plan should cover |
Why dental offices get PR-96
- Cosmetic procedures such as whitening or veneers.
- Implants or orthodontics on a plan without that benefit.
- Adjunctive procedures the plan excludes, such as some sealants on adults or certain diagnostic tests.
- Services during a waiting period, which some payers report under 96 rather than a waiting-period code.
What to do about PR-96
- Check the remark code for the exclusion the payer applied.
- If the plan should cover it, appeal with the plan’s benefit summary.
- If it is genuinely excluded, move the amount to the patient balance.
- Give patients a written estimate for non-covered work before treatment, and have them sign it.
Can you bill the patient for PR-96?
Yes. The PR group means the patient owes it. Many PPO contracts still limit the fee for some non-covered services, and some states regulate this, so check what you can charge.
Questions about a specific EOB line?
Ask Sai Biller, our free dental insurance chatbot. Type the codes and amounts from the line, leave out patient details, and it explains what happened and what to do next. For offices posting every day, Sai for Dentists reads each EOB line as it posts, checks the allowed amount against your contracted fee and lists every denial, downgrade and underpayment for your team.
Sources
- X12 claim adjustment reason codes and remittance advice remark codes. Meanings here are paraphrased; see X12 for the official wording.
- American Dental Association, CDT: Code on Dental Procedures and Nomenclature. Procedure labels here are our own short descriptions.
- Payers apply these codes differently. Your contract and each payer’s provider manual decide what applies to your office.
Common questions
What is the difference between PR-96 and CO-96?
Both say the service is not covered. PR-96 puts the amount on the patient. CO-96 makes it the office’s contractual obligation, so it cannot be billed to the patient. If you think the patient should owe it, ask the payer why it was coded CO.
Can I charge my full fee for a non-covered dental service?
It depends on your contract and your state. Some PPO contracts and some state laws limit fees for non-covered services; others allow your full fee. Check before billing.
