PR-1 means the payer applied the amount to the patient’s deductible. It is not a denial: the claim was processed, and the amount is the patient’s responsibility. Bill any secondary coverage first, then bill the patient for what remains.
What does PR-1 mean?
PR is the group code for Patient Responsibility, and CARC 1 is officially described as “Deductible Amount.” The wording is published in the X12 Claim Adjustment Reason Code list (opens in a new tab).
The allowed amount for the service was applied, in whole or in part, to the deductible the patient must meet before the plan starts paying. Deductibles reset each plan year, so PR-1 is most common in the first months of the year and with high-deductible health plans.
Common causes of PR-1
| Cause | Where to look |
|---|---|
| Patient has not met the annual deductible | Eligibility response and the ERA |
| New plan year reset the deductible | Plan year start date in the eligibility response |
| High-deductible health plan | Plan type in the eligibility response |
| Service not covered before the deductible under the plan | Plan benefits |
How to fix a PR-1 adjustment
- Confirm the amount matches the allowed amount and the deductible remaining in the eligibility response.
- If the patient has secondary coverage, such as Medicaid, a Medigap plan or a spouse’s plan, send the claim to the secondary payer before billing the patient.
- Post the amount to patient responsibility and send a clear statement that shows the payer’s decision.
- Offer payment options and apply any payment collected at the visit.
Is PR-1 a denial I should appeal?
No. PR-1 reflects the plan’s benefit design, not an error. Ask the payer to reprocess only if the eligibility response shows the deductible was already met, or the service should have been covered before the deductible, as many preventive services are.
How to prevent PR-1
- Check remaining deductible during eligibility verification before the visit.
- Give patients a cost estimate for planned services.
- Collect a reasonable deposit at check-in for high-deductible plans.
- Follow your contracts and any applicable state rules on patient billing and collections.
Frequently asked questions
What is the difference between PR-1, PR-2 and PR-3?
They are all patient responsibility. CARC 1 is deductible, 2 is coinsurance and 3 is copay.
Can PR-1 be written off?
Routinely waiving deductibles can violate payer contracts and, for government programs, federal rules. Financial hardship policies should be documented and applied consistently.
Why did a preventive visit apply to the deductible?
Usually because a problem-oriented service was billed on the same day, or the service did not meet the plan’s preventive criteria. Check the coding before billing the patient.
Related denial code guides
- How to read a claim denial: CARCs, RARCs and group codes
- CO-16 denial code
- CO-97 denial code
- CO-197 denial code
- CO-50 denial code
- CO-4 denial code
Code descriptions are quoted from X12 at the time of writing and are revised from time to time. Payer policies and your contracts decide what is billable and appealable.
Patient balances going uncollected?
We help practices check deductibles before visits and turn PR balances into clear, timely statements.