When you receive a medical bill, it often includes an Explanation of Benefits (EOB) from your insurance company. The EOB details how the insurer processed the claim submitted by your healthcare provider. Within this document, Adjustment Reason Codes (ARCs) explain why a claim was paid, adjusted, or denied. These codes determine who is financially responsible for the service. PR 242 is a specific code that signals a shift in financial responsibility to the patient.
The Meaning of PR 242
PR 242 is an Adjustment Reason Code used in medical billing. The prefix “PR” stands for Patient Responsibility, meaning the insurer has determined the financial burden shifts to the patient, who will be billed for the balance.
The numerical code “242” specifies the reason for denial: “Services not provided by network/primary care providers.” This means the professional who performed the service was not contracted with the patient’s plan, or the service lacked necessary authorization from a network provider. The insurer refuses coverage because the provider is considered “out-of-network.” This typically occurs when a specialist, lab, or imaging center bills for a service, and the patient’s policy requires the use of contracted providers.
Common Scenarios Leading to PR 242
PR 242 often appears when a patient receives care at an in-network facility, but the specific service is rendered by a non-contracted provider within that facility.
A common example involves lab work ordered by an in-network primary care physician. If the doctor sends samples to a laboratory that lacks a contract with the insurance plan, the lab’s claim will be denied with PR 242, shifting the cost to the patient.
Another source of surprise billing involves facility-based services, such as a hospital stay or outpatient procedure. While the hospital may be in-network, specialized providers working there—such as anesthesiologists, pathologists, or radiologists—might belong to independent, out-of-network groups. The claim from the out-of-network group could be denied with PR 242, resulting in a substantial unexpected bill. Similarly, a referral to a specialist by an in-network doctor can trigger this code if the patient fails to confirm the specialist’s network status beforehand.
Patient Steps After Receiving PR 242
When you receive an EOB with a PR 242 denial, the first action is to confirm the billing provider’s network status on the specific date of service. Cross-reference the provider’s name and facility location against your insurance plan’s official directory to verify the out-of-network claim. If the provider was listed as in-network at the time of service, this suggests a billing error that the provider’s office can correct.
If the denial is confirmed as out-of-network, contact the billing provider to discuss the charge. Inquire if they are willing to accept the in-network rate or offer a discount, especially if the service occurred unknowingly at an in-network facility. Many provider groups have policies to reduce the balance in these “surprise billing” situations.
It is also beneficial to research federal and state consumer protections, such as the No Surprises Act, which took effect in January 2022. This law protects patients from surprise medical bills for certain emergency and non-emergency services provided by out-of-network providers at an in-network facility. If your PR 242 denial falls under these protected categories, reference the protection when speaking with the provider or the insurance company.
If negotiation is unsuccessful, the next formal step is to file an appeal with your insurance company. This requires submitting a letter detailing why the service should be covered, along with supporting documents, including the EOB and relevant policy excerpts. Clearly explain why the service should have been processed as in-network, such as being unable to choose a provider during an emergency or being referred without proper disclosure. Maintaining a detailed record of all communications is important throughout this resolution process.