PR-242 Denial Code: Services Not Provided by Network or Primary Care Providers

PR-242 is Claim Adjustment Reason Code 242 with group code PR. CARC 242 means services were not provided by network or primary care providers. CO-242 means the same CARC with group code CO. Search demand often uses “denial code pr 242,” so this page uses slug pr-242 while covering both group codes in the body. (Primary sources: X12 Claim Adjustment Reason Codes · CMS Medicare Claims Processing Manual, Ch. 22, §60.1)

Quick answer: Confirm the member’s network and PCP rules on the date of service. If you were in network or had a valid referral/authorization, appeal with roster proof or the auth number. If you were truly out of network and group code is PR, bill the patient per plan rules (or negotiate a self-pay rate). If group code is CO, treat it as a contractual write-off unless a notice shifts liability.

Part of our denial codes library. Written by Manikandan, a revenue cycle management specialist with more than 10 years of US medical billing experience. Last reviewed: 11 October 2026. Official code wording is quoted word for word from X12; Medicare rules link to their CMS or Medicare contractor source.

PR-242 / CO-242 denial code description (official X12 wording)

X12 Claim Adjustment Reason Code 242, verbatim:

“Services not provided by network/primary care providers.”

Source: X12 Claim Adjustment Reason Codes, checked 11 October 2026. Start: 06/03/2012 | Last Modified: 06/02/2013. Notes: This code replaces deactivated code 38.

Related CARC 243: “Services not authorized by network/primary care providers.” (same start/last-modified; also replaces deactivated code 38).

The CARC is 242. Payers attach group code PR or CO (occasionally OA/PI) depending on who they assign for leftover dollars.

What PR-242 and CO-242 mean in plain English

• CARC 242 means the service was performed by a provider who is not in the plan’s network and/or is not the member’s assigned primary care provider when the plan requires PCP-directed care.
• PR-242 — payer says the patient is responsible (common on HMO/EPO products when members go out of network without coverage).
• CO-242 — payer says the amount is a contractual/provider write-off (seen when a contracted rule zeros the line without assigning patient liability).

Always trust the group code on the remit. Separate 242 (wrong network/PCP provider) from 243 (network/PCP did not authorize the service).

PR-242 vs CO-243, CO-197, CO-109 and CO-B7

Code	Official X12 text	Difference
242	Services not provided by network/primary care providers.	Rendering provider not network/PCP
243	Services not authorized by network/primary care providers.	Network/PCP did not authorize
197	Precertification/authorization/notification/pre-treatment absent.	Missing auth/notification — see CO-197
109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.	Wrong payer — see CO-109
B7	This provider was not certified/eligible to be paid for this procedure/service on this date of service.	Enrollment/certification — see CO-B7

242 is a network roster / PCP assignment problem. 243 is an authorization-from-network/PCP problem. 197 is broader missing precert.

Group code matrix for CARC 242

Group + 242	Who carries the amount	Typical next step
PR-242	Patient	Verify network; bill patient or offer cash-pay if OON and uncovered
CO-242	Provider	Verify roster; write off unless notice shifts liability
OA-242	Neither fits cleanly	Read remarks; rare
PI-242	Payer-initiated	Non-Medicare; investigate contract

CMS Ch. 22 §60.1: PR amounts “may be billed to the patient or insured”; CO amounts are generally provider write-offs not billed to the patient.

Remark codes that help with CARC 242

RARC	Role
N130	Consult plan benefit documents/guidelines for restrictions
N381	Alert: consult contractual agreement — see N381
N54	Claim information insufficient about whether services rendered by contracted/network provider (when present)
N95 / plan-specific remarks	Network or referral messaging — open the exact remark

Always confirm whether the plan is HMO (PCP gate), EPO (no OON benefit), PPO (OON benefit at lower rate), or Medicare Advantage with network rules.

Where PR-242 / CO-242 shows up in the 835

SVC*HC:99213*200.00*0.00~
CAS*PR*242*200.00~
LQ*HE*N130~

• Specialist visit denied because the rendering NPI is out of network on an HMO without OON benefits.
• Group PR → patient responsibility after network edit.

Illustrative only.

How to fix PR-242 / CO-242: decision path

1. Read group code + remark codes. PR vs CO decides patient billing.
2. Confirm plan type and DOS network status for the rendering and billing NPIs (and group taxonomy if relevant).
3. Check PCP assignment and referral. Was a PCP referral or auth on file? If the issue is auth, you may actually need 243/197 workflows.
4. Roster errors — if you were credentialed/in-network on DOS, appeal with payer roster letter, effective dates, and W-9/tax ID proof.
5. Wrong plan product — verify eligibility screenshot; member may have switched to an EPO mid-year.
6. If truly OON and PR — bill the patient, discuss self-pay, or check secondary coverage.
7. If truly OON and CO — write off; do not balance-bill unless a valid notice shifted liability.
8. Forward-looking — real-time eligibility with network flags; referral tracking before the visit.

Medicare and commercial notes

Medicare FFS. Traditional Medicare is not a closed commercial network in the same way; CARC 242 is far more common on Medicare Advantage, Medicaid managed care, and commercial HMO/EPO products. Match the remittance you received.

Commercial. “denial code pr 242” is everyday language on HMO specialty claims without a PCP referral path, and on EPO claims when members leave the network. PPO OON claims may pay at a lower rate with different CARCs (including 45) rather than a hard 242.

Related 243. If the network provider existed but did not authorize the service, work 243 (and often CO-197), not 242.

Worked example (illustrative)

For example, an HMO member sees a dermatologist without a PCP referral. The remit returns PR-242 with N130. Group code PR.

Reading it: services not provided by network/PCP pathway; patient liable per remit.

Fix: confirm the dermatologist’s network status and whether a referral was required. If a referral existed but was not linked, appeal with the auth/referral number. If none existed and the plan has no OON benefit, bill the patient and educate scheduling staff.

Prevention: eligibility view that shows “referral required”; hold non-urgent specialty scheduling until referral is on file.

PR-242 / CO-242 appeal or patient-notice template

[Date]
[Payer] Appeals / Provider Service
[Address, fax or portal]

Re: CARC 242 (network/primary care provider) — [appeal / reconsideration]
Patient: [Name]   Member ID: [ID]   DOB: [MM/DD/YYYY]
Claim number: [Claim #]   Date(s) of service: [MM/DD/YYYY]
CPT/HCPCS: [Code]   Group code on remit: [PR / CO]
Rendering NPI: [NPI]

The remittance shows CAS*[PR/CO]*242 with remark [code]. Please reprocess
because:
[ ] Rendering provider was in-network effective [date] (roster letter enclosed).
[ ] Valid PCP referral / authorization [number] was on file for DOS.
[ ] Member eligibility showed PPO/OON benefits that should apply.

Enclosed: remit, claim, roster proof, referral/auth, eligibility screenshot.

[Name, credentials]  [Practice, NPI]  [Phone / email]

Patient financial notice (when PR-242 is confirmed):

We received a remittance showing network/PCP rules (CARC 242) with patient
responsibility for DOS [date], charge $[amt]. Your plan reports these
services were not provided by a network or primary care provider under
your benefit. Please contact us by [date] to arrange payment or to share
other coverage.

Prevention checklist

• Verify network status for rendering NPI on every eligibility check.
• Capture PCP name and referral requirements for HMO/gatekeeper plans.
• Distinguish 242 (not network/PCP provider) from 243 (not authorized by network/PCP).
• Keep roster effective-date letters for appeals.
• Respect PR vs CO when building patient statements.
• Offer estimates for known OON elective services before the visit.
• Train staff with the CARC & RARC guide.

Related denial codes

• CO-197: precertification/authorization absent.
• CO-109: wrong payer/contractor.
• CO-B7: provider not certified/eligible on DOS.
• N381: consult contractual agreement (alert).
• PR-204: not covered under current benefit plan.
• CARC & RARC guide.

In short

CARC 242 means the network or PCP rule failed. Prove roster or referral when you have it; bill patients only for true PR; prevent the next miss with eligibility network flags.

FAQ

Quick facts

Item	Value
X12 code	242
X12 start	06/03/2012
Last modified	06/02/2013
Slug	pr-242 (covers PR-242 and CO-242)
Last reviewed	11 October 2026
Page type	WordPress Page under Denial Codes hub 183
Primary keyword	denial code pr 242

Sources

• X12, Claim Adjustment Reason Codes (CARC 242, 243, 197, 109, B7). CARC 242 Start 06/03/2012, Last Modified 06/02/2013; replaces deactivated code 38. Accessed 11 Oct 2026.
• X12, Remittance Advice Remark Codes. Accessed 11 Oct 2026.
• CMS, Medicare Claims Processing Manual (IOM 100-04), Ch. 22, §60.1 Group Codes

Access dates and figures on this page were checked on 11 October 2026 against X12 and CMS sources.

Last reviewed: 11 October 2026 · This page is educational and doesn’t replace payer-specific instructions.