PR-49
Sometimes appealableRoutine or preventive exam (non-covered)
Group PR — Patient Responsibility — an amount the plan says may be billed to you, the patient.
PR-49 means the service was processed as a routine/preventive exam or a screening done with a routine exam, which the plan is treating as non-covered as billed. It's billed as Patient Responsibility (PR).
This one is worth a close look: under the ACA, many preventive services are supposed to be covered at no cost-share. A PR-49 can appear when a preventive visit was miscoded as routine, or when a diagnostic service got lumped in with a routine exam.
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Why you're seeing PR-49
- A preventive service was coded as a general routine exam rather than as covered preventive care.
- A diagnostic test was billed together with a routine exam and denied.
- The plan doesn't cover the specific routine service as billed.
Can you appeal it?
Worth appealing when a covered preventive service was miscoded as routine — many preventive services must be covered at no cost-share.
What to do next
- 1Check whether the service is a preventive service that should be covered at no cost-share.
- 2Ask the provider whether it was coded as routine when it should have been coded as preventive.
- 3Have the provider recode and resubmit if a preventive service was miscoded.
- 4Appeal if a covered preventive service was wrongly processed as non-covered routine care.
Evidence that helps
- The list of preventive services covered at no cost-share under your plan.
- The visit record showing the service was preventive.
Frequently asked questions
Aren't preventive services free?
Many are — under the ACA, a defined set of preventive services must be covered at no cost-share. If PR-49 appears on what should be a covered preventive service, it may have been miscoded as routine, which the provider can correct.
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Other common denial codes
Last reviewed July 18, 2026. Denial-code lists (CARC/RARC) are updated three times a year; we review these explanations against the current list.
Sources & references
These explanations are written in plain language and based on the authoritative sources below. Always confirm the specifics against your own plan documents and denial letter.
- ASC X12 — Claim Adjustment Reason Codes (CARC)
The standards body that maintains the official CARC list (the CO/PR codes), updated three times a year.
- CMS / X12 — Remittance Advice Remark Codes (RARC)
The remark codes (N-/M- codes) that accompany a CARC and give the specific reason for an adjustment.
- HealthCare.gov — Appealing a health plan decision
Official overview of internal appeals and external review rights for Marketplace and most private plans.
- U.S. Department of Labor — ERISA claims & appeals
Governs claim and appeal procedures and deadlines for most employer-sponsored (ERISA) health plans.
- HealthCare.gov — Preventive care benefits
The set of preventive services most plans must cover at no cost-sharing.
- Your state's insurance regulator
State agencies enforce external review and consumer protections; find yours via the NAIC directory.
Important: this is not legal or medical advice.
AppealBrain is a free, self-help tool that helps you draft an appeal letter using the information you provide. We are not a law firm, medical provider, or insurance company, and using this tool does not create an attorney–client relationship. Appeal rules and deadlines vary by plan and state — always review your own denial letter and plan documents, and consider consulting a licensed professional for your specific situation. We do not guarantee any outcome.