PR-1 — Patient Responsibility (Deductible/Coinsurance/Copay)

Denial Identifier

• Primary CARCs (Group Code PR): CO-1/PR-1 — "Deductible Amount." PR-2 — "Coinsurance Amount." PR-3 — "Co-payment Amount." (X12)
• These are standard, expected patient-liability adjustments, not typically "denials" in the sense of an error — they are included here because the user's revenue-cycle team must correctly distinguish them from true denials.
• Common RARCs: generally none required; occasionally an alert RARC (e.g., appeal-rights language) accompanies the EOB sent to the patient.

Plain-Language Meaning

• The payer has processed and approved the claim; this specific dollar amount is the patient's contractual share of the cost (deductible, coinsurance, or copay), not a payer denial of the service itself.

Why This Amount Applies

• Patient/COB information: patient's deductible has not yet been met for the benefit period, or the plan design requires coinsurance/copay for this service type
• Registration: patient not informed of estimated liability before the service (a financial- counseling gap, not a claims error)

Information the Biller Must Review

• ERA/EOB adjustment amounts and codes, patient's plan benefit summary (deductible/coinsurance/copay structure), patient's accumulator status (deductible met-to- date), any secondary coverage that might offset the liability (cross-reference D04).

What Needs to Be Corrected

• Claim correction: Only if the PR amount appears calculated incorrectly relative to the plan's actual benefit structure (rare; typically a payer processing question, not a claim data fix).
• Upstream correction: Registration/Patient Financial Services should provide accurate liability estimates and financial counseling before the service when possible.

Resolution Workflow

• Confirm the PR amount matches the plan's stated deductible/coinsurance/copay structure.
• Check for secondary coverage that might cover some or all of the patient liability.
• If a secondary payer applies, bill secondary before billing the patient.
• If no other coverage applies and the amount is correctly calculated, proceed with standard patient billing/collections workflow.
• Document any discrepancy found and correct with the payer if the PR amount appears miscalculated.

Department Most Likely Responsible

• Resolves current account: Patient Financial Services/Billing. Prevents recurrence (of patient confusion/complaints): Registration/Patient Access — pre-service financial counseling and liability estimates.

Prevention Control

• Pre-service benefit and liability estimation at registration; secondary-coverage/COB check before generating a patient statement; QMB/dual-eligible balance-billing restriction checks before billing Medicaid-eligible patients.

Escalation Trigger

• Patient disputes the liability calculation; possible dual-eligible/QMB status not yet flagged (billing this population directly for Medicare cost-sharing can violate federal balance-billing rules); secondary coverage discovered after billing has begun.

Sample Scenario

• Scenario: Patient balance shown as PR-1/PR-2 on the EOB.
• Finding: Deductible had not been met; no secondary coverage exists.
• Action: Standard patient statement generated per normal billing cycle; no claim correction needed.

Resolution path at a glance

AI Search Terms / Synonyms

• PR1; PR2; PR3; patient responsibility; deductible; coinsurance; copay; balance billing.

AI Answer Guardrail

• Confirm there is no secondary payer, QMB/dual-eligible status, or other regulatory/contractual restriction on billing the patient before advising that a PR amount should be collected from the patient.

Sources

• X12 CARC list