Deductible
The payer applied this amount to the patient's yearly deductible. Nothing is wrong with the claim; the patient owes this part.
PR = Patient Responsibility. The patient owes this amount (deductible, coinsurance, copay or a non-covered service the patient agreed to pay for). The same reason code can appear with a different group code; the group decides who may be billed.
Usual causes
- The patient has not yet met the plan deductible for the year.
- High-deductible plans: most visits early in the year land here.
- A secondary payer may pick up the amount if the patient has one.
The fix
Bill the patient, or send the claim with the primary remittance to the secondary payer first. Check eligibility before the visit so the front desk can collect at the time of service.
Appeal or corrected claim?
Nothing to appeal or correct. If the patient shows the deductible was already met, ask the payer to reprocess with the updated accumulator.
Deadline to watch
None for the payer. Your own patient statement cycle and any secondary payer's timely filing limit apply.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
Often seen together
Deductible applied for a Qualified Medicare Beneficiary. Do not bill the patient; bill Medicaid as the secondary payer.
PR-1 in short
What does PR-1 mean?
The payer applied this amount to the patient's yearly deductible. Nothing is wrong with the claim; the patient owes this part. The official X12 text reads: "Deductible Amount"
What usually causes a PR-1 denial?
The patient has not yet met the plan deductible for the year. High-deductible plans: most visits early in the year land here. A secondary payer may pick up the amount if the patient has one.
How do I fix PR-1?
Bill the patient, or send the claim with the primary remittance to the secondary payer first. Check eligibility before the visit so the front desk can collect at the time of service.
Should I appeal PR-1 or send a corrected claim?
Patient responsibility. Nothing to appeal or correct. If the patient shows the deductible was already met, ask the payer to reprocess with the updated accumulator.
What deadline applies to PR-1?
None for the payer. Your own patient statement cycle and any secondary payer's timely filing limit apply.