PR 242: Out-of-Network Provider
The provider was out of network, or not the patient's assigned primary care provider.
Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
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- No BAA
- No charge
- No pitch
What PR 242 means
PR: Patient responsibility. This one goes on the patient statement.
So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
The same code, a different prefix. 242 also arrives as CO 242. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says CO 242, read that page instead.
Is It Worth Appealing?
Usually recoverable. Appeal it. The money is usually there.
Why It Fires
In the order we see it.
No referral from the assigned primary care provider.
The provider is out of network for that specific plan product, though in network for others from the same payer.
Emergency or urgent care, where network rules are usually waived.
How to Appeal PR 242, Step by Step
Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
- 1Step 1: Read the remark code. Find the remark code printed next to PR 242 on the 835 or EOB. It says what the payer wants back.
- 2Step 2: Find the cause. Match the denial to one of the 3 causes in Why It Fires above, and fix that one.
- 3Step 3: Take the first action. Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
- 4Step 4: Attach the documentation. The referral or authorisation, with its date range. Documentation that the care was emergent, where that applies. The network participation record for that specific plan product.
- 5Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window. See what an appeal letter must contain and the filing limits by payer.
The common mistake. Do not bill the patient before checking. Balance billing an out-of-network denial that was actually emergent is a compliance problem, not just a mistake.
Free: the Denial Code Appeal Playbook. 53 codes on one sheet: appeal, fix and resubmit, or let it go, and what to attach. Get the playbook
PR 242 description
The provider was out of network, or not the patient's assigned primary care provider.
The provider was out of network, or not the patient's assigned primary care provider. So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Related Codes
CO 185
The rendering provider is not eligible to perform the service billed.
Read the CO 185 pagePR 27
Coverage had ended on the date of service.
Read the PR 27 pagePR 26
Service fell before coverage started.
Read the PR 26 pageCO B7
The provider was not certified or eligible for this service on that date.
Read the CO B7 page
Your Questions Answered
What does PR 242 mean?
The provider was out of network, or not the patient's assigned primary care provider. Patient responsibility. This one goes on the patient statement.
Can you appeal PR 242?
Usually recoverable. Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
Why does PR 242 happen?
No referral from the assigned primary care provider. The provider is out of network for that specific plan product, though in network for others from the same payer. Emergency or urgent care, where network rules are usually waived.
What documentation wins a PR 242 appeal?
The referral or authorisation, with its date range. Documentation that the care was emergent, where that applies. The network participation record for that specific plan product.
How do I appeal a PR 242 denial?
Step 1: Read the remark code. Find the remark code printed next to PR 242 on the 835 or EOB. It says what the payer wants back. Step 2: Find the cause. Match the denial to one cause: No referral from the assigned primary care provider. The provider is out of network for that specific plan product, though in network for others from the same payer. Emergency or urgent care, where network rules are usually waived. Step 3: Take the first action. Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three. Step 4: Attach the documentation. The referral or authorisation, with its date range. Documentation that the care was emergent, where that applies. The network participation record for that specific plan product. Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window.
Most searched: CO 97 · CO 96 · OA 23 · PR 204 · CO 109 · CO 197 · CO 45 · CO 50
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