PR-49
PR · Patient Responsibility
PR-49 Denial Code: Routine or preventive service the plan doesn't cover
A routine or preventive exam/screening (or a service performed alongside one) isn't covered under the plan, so it falls to the patient. Check whether the service was actually diagnostic.
- Group code
- PR - Patient Responsibility
- Code type
- CARC
- Billable to patient?
- Yes - patient responsibility
- Appealable?
- Only if the service was actually diagnostic
- Category
- Coverage & Benefits
On a remittance
CAS*PR*49*125.00On a paper EOB it shows as PR-49.What PR-49 means
PR-49 means the service was treated as routine or preventive and isn't a covered benefit, so it becomes patient responsibility. The most common recoverable scenario is a diagnostic service coded or bundled as preventive - if the visit was medically driven rather than routine, recoding it correctly may make it payable. Otherwise it is patient responsibility per the plan.
Common causes
- The exam or screening is a routine/preventive service the plan doesn't cover.
- A diagnostic service was coded or grouped as preventive.
- The preventive benefit was already used for the period.
- The plan excludes this routine service.
How to fix it
- Confirm whether the service was genuinely preventive or actually diagnostic.
- If diagnostic, recode with the appropriate diagnosis and modifier and resubmit.
- If genuinely routine/non-covered, bill the patient per the plan and your financial policy.
- If the plan should cover the preventive service, appeal with the benefit details.
How to prevent it
- Verify preventive vs diagnostic benefit rules before the visit.
- Code the encounter to reflect its actual diagnostic or preventive intent.
- Set patient expectations on non-covered routine services up front.
Only if the service was actually diagnosticAppeal when the service was actually diagnostic (not routine/preventive) and should be covered - recode appropriately and submit documentation. A genuinely non-covered routine service is patient responsibility.
Appeal letter template
Fill in the bracketed fields, attach your supporting documentation, and send through the payer's appeal channel. This is a starting point — adjust to your payer's requirements.
Re: Preventive vs Diagnostic Appeal (PR-49) - Claim [Claim Number] Patient: [Patient Name] | Member ID: [Member ID] Date(s) of Service: [DOS] | Service: [CPT/HCPCS] To Whom It May Concern: Claim [Claim Number] was denied under PR-49 as routine/preventive. This service was diagnostic, not routine: [brief clinical reason / presenting complaint]. The correct diagnosis is [ICD-10], as documented in the enclosed records. We request that the claim be reprocessed as a diagnostic, covered service. Sincerely, [Your Name], [Practice Name] | [Phone] | [NPI/TIN]