PR-242 denial code: services not provided by network or primary care providers

Claim adjustment reason code 242 says: services not provided by network or primary care providers. The patient's plan pays only for care from providers in its network, or care arranged through the patient's primary care provider, and this service wasn't.

With group code PR, the plan has assigned the amount to the patient. That is the plan's position, not always the end of the story.

• The plan is an HMO or EPO that pays nothing out of network, and your practice or this clinician isn't in its network.
• The clinician isn't credentialed with the plan yet, even though the practice is.
• The plan requires a referral from the primary care provider and there wasn't one on file, or it named a different provider.
• The patient's plan changed to one with a narrower network.

Often, but check three things first:

• Did the patient know? Telling patients before the visit that you are out of network for their plan, and what they will owe, is what turns this balance from a surprise into an agreed charge.
• Do federal surprise-billing protections apply? They limit balance billing in some situations, such as emergency care, and some services at in-network facilities.
• Is it really out of network? If the clinician is credentialed or a referral existed, appeal instead.

1. Check the clinician's network status with the plan for the date of service.
2. If a referral was required, find it. If it existed, appeal with a copy.
3. If the plan's network listing is wrong, appeal with your participation agreement or credentialing approval.
4. If the denial stands, bill the patient under your financial policy, with the explanation from the plan.

• Check network status for the plan and the clinician at booking, not just the practice.
• Get the primary care referral before the visit when the plan requires one, and make sure it names the right provider.
• Tell out-of-network patients what they will owe before they are seen.

PR-242 is decided before the patient walks in, so it is prevented at booking and before the visit.

Claira Health's AI agents confirm coverage and the right payer before the visit, so this denial is stopped at the front desk instead of coming back weeks later. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

Book a 20-minute call and bring a PR-242 you've had recently.