Not covered under your benefit plan
The plan says your specific plan excludes this. Sometimes true; sometimes the service fits a covered category the reviewer missed.
Official meaning (X12 code 204): This service/equipment/drug is not covered under the patient's current benefit plan.
Who pays
PR-204. Patient responsibility: the plan says this part is yours to pay (deductible, copay, coinsurance, or a non-covered service).
What to do
- Ask for the exact plan language relied on.
- Appeal if your service fits a covered benefit or a state mandate.
- For drugs, ask your doctor to request a formulary exception.
If you appeal
Ask for the plan document section the denial relies on. Denials often hinge on a definition that your situation fits better than the reviewer assumed. State mandates may also require coverage.
Deadlines for the first appeal
- employer plan
- 180 days from the notice
- ACA Marketplace plan
- 180 days from the notice
- Medicare Advantage plan
- 65 days from the notice
- Original Medicare
- 120 days from the notice
- Medicaid
- 60 days from the notice
The date printed on your notice controls. Urgent care can be appealed on an expedited (72-hour) basis.
What the data show
Averages across all denials; not a prediction for yours.
Appeal this denial
Upload your denial. We draft the appeal around this code, you approve it, and we fax it to your plan and mail a certified copy. Free check first, then $59.
General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.