PR-238 reduces payment for the portion of a billed date span during which the member was not eligible. Inpatient stays and continuous courses that cross a coverage boundary produce it.
What PR-238 means
A stay that begins before a termination and continues after it, or begins during a waiting period and continues past its end, is partly covered and partly not. Billed as one span, the claim carries both. Splitting the claim at the eligibility boundary is the resolution, and it usually recovers the covered portion in full — which is why this rewards correction more than argument.
Why PR-238 fires
- An inpatient stay crossed a coverage termination date.
- A course of care began before the effective date and continued past it.
- Coverage changed mid-span between two plans.
- The eligibility boundary in the payer's record is wrong.
Is PR-238 worth appealing?
Sometimes worth appealing
How to resolve or appeal PR-238
- 1
Identify the eligibility boundary
The exact date coverage began or ended in the payer's record.
- 2
Split and rebill
Each portion to the coverage that applies to it, rather than appealing the reduction.
PR-238 — frequently asked
Why not appeal the reduction?
What if the boundary is wrong?
Reason-code meanings are paraphrased from the X12 Claim Adjustment Reason Code list for plain-language reference; they are not reproduced verbatim. This is general information, not legal, coding, or medical advice — always confirm against the payer's remittance and policy.
Turn this PR-238 denial into a signed appeal
Upload the denied EOB and Merits builds a complete PR-238 appeal — the argument, the payer's own coverage criteria, and your federal appeal rights, every claim cited to a named source. $9 a letter. No account.