PR-238 shows up when one claim covers days on both sides of a coverage change. The payer pays the days when the patient was covered and moves the rest to patient responsibility. It is common on inpatient stays, long therapy claims and monthly rentals. The real question is whether another payer covered those days. (Primary source: X12 Claim Adjustment Reason Codes)
In brief: CARC 238 reads “Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)”. Confirm the coverage dates, look for other coverage for the ineligible days, bill that payer if there is one, and only then bill the patient.
Part of our denial codes library. Written by Manikandan J, CPC, CRCR, who has worked eligibility and patient balance accounts for hospitals and health plans. Published 23 October 2026. Last updated: 23 October 2026. Code wording quoted word for word from X12.
What does PR-238 mean?
| Field | Value |
|---|---|
| Code | 238 |
| Description | “Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)” |
| Start | 03/01/2012 |
| Last modified | 07/01/2013 |
Source: X12 Claim Adjustment Reason Codes, checked 23 October 2026.
PR-238 is a partial payment. The payer paid the covered days and cut the rest. Group code PR means patient responsibility, so the patient may owe the cut amount unless another payer covers it. An eligibility span is the start and end date of coverage on the payer’s file.
Common causes of PR-238
- Coverage ended mid stay. For example, a job ended and the employer plan stopped on the last day of the month.
- Coverage started late. Such as a new plan that began a few days into a hospital stay.
- A gap between plans. For instance, a patient between Medicaid renewal dates.
- Retro changes. The plan back-dated a termination after the claim was billed.
PR-238 is the payer’s own split. Its sister code, CO-239, is used when the payer wants you to split the claim yourself.
Example scenario (fictional names), part 1
PR-238 Denial Example: What Happened
Maria Lopez works patient accounts at Lakeshore Community Hospital. A 7 day inpatient stay came back with most days paid and a CAS*PR*238 line for the last two days.
The patient’s employer plan ended on the last day of the month, and the stay ran two days into the next month. The system dropped the PR amount straight onto the patient statement.
Should the patient get that bill yet? Keep reading, or jump to how the PR-238 denial was resolved.
How to work PR-238
- Confirm the dates. Check the coverage end or start date with the payer.
- Look for other coverage. Ask the patient about a new plan, a spouse’s plan, COBRA or Medicaid.
- Bill the other payer. Send the ineligible days to that payer with the first payer’s remit.
- Check retro changes. If the payer changed the dates later, ask whether the change is final.
- Then bill the patient. Only after other options are checked, and offer financial help screening.
No claim box caused PR-238. The payer already made the split, so there is no field to correct.
Example scenario (fictional names), part 2
How the PR-238 Denial Was Resolved
Maria called the patient. He had started a new job and his new plan began on the first of the month, the same day the old plan ended.
Fix: She billed the two remaining days to the new plan with the first payer’s remit attached, and held the patient statement.
Outcome: The new plan paid its share under its own rules. The patient only got a bill for his cost sharing, and Lakeshore now holds PR-238 balances for an eligibility check before statements go out.
Names and details are illustrative; no real patient data.
PR-238 compared with nearby codes
| Code | Meaning | Who splits the claim |
|---|---|---|
| PR-238 | Reduction for the ineligible period | The payer |
| CO-239 | Spans periods; rebill separate claims | You |
| CO-27 | Expenses after coverage ended | Not split; denied |
| CO-26 | Expenses before coverage began | Not split; denied |
To read the split line by line, see how to read an explanation of benefits.
FAQ
What does PR-238 mean?
The claim covered days with and without coverage. The payer paid the covered part and moved the rest to patient responsibility.
Does the patient owe PR-238?
Possibly, but check for other coverage first.
How is PR-238 different from CO-27?
CO-27 denies a service after coverage ended. PR-238 splits one claim that spans the change.
Do I need to rebill?
Not to the same payer. Bill the ineligible days to any other payer that covers them.
Can retro terminations cause PR-238?
Yes. A plan can back-date a termination after the claim was paid.
Sources
How we checked: the code quote on this page was matched word for word with the X12 CARC list on 23 October 2026.
- X12, Claim Adjustment Reason Codes (CARC 238). Accessed 23 Oct 2026.
- CMS, Coordination of Benefits overview. Accessed 23 Oct 2026.
- CMS, Internet-Only Manuals. Accessed 23 Oct 2026.
Last updated: 23 October 2026 ยท Educational content; not legal advice.