Official CARC description: “This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam.” Here’s what it actually means, why it fires, and how to get the claim paid.
The payer classified the visit as routine and pushed it to the patient. The preventive-vs-diagnostic line is the most miscoded boundary in outpatient billing — in both directions.
Liability group: PR = Patient Responsibility — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Re-read the note: was a specific complaint/condition evaluated?
If diagnostic: corrected claim with the condition ICD-10 primary
Screening-turned-diagnostic colonoscopies: modifier PT/33 rules apply
If truly routine: patient liability stands — collect with the plan's rules
Appeal when the visit was genuinely diagnostic: attach the note showing the presenting problem and re-sequenced diagnoses. Cite the plan's own preventive-services definitions.
Fill in the denial facts — use placeholders, never real patient data (the letter keeps [PATIENT NAME]-style fields so you can merge real details privately). A payer-ready draft with an enclosure checklist comes back in ~20 seconds.
Your appeal letter draft will appear here.
This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. In practice: The payer classified the visit as routine and pushed it to the patient. The preventive-vs-diagnostic line is the most miscoded boundary in outpatient billing — in both directions.
PR stands for Patient Responsibility — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Appeal when the visit was genuinely diagnostic: attach the note showing the presenting problem and re-sequenced diagnoses. Cite the plan's own preventive-services definitions.