Denial code · group PR
PR-1: Some or all of the allowed amount went to the deductible, and the patient owes that part
Short answer
PR-1 is not a denial. The payer allowed the service, applied some or all of the allowed amount to the deductible and paid any remainder. The PR-1 amount is patient responsibility: bill the patient that amount, the part of the allowed amount applied to the deductible, never the full charge, and only after any secondary plan has been billed. Never bill it to a patient in the Qualified Medicare Beneficiary program.
Look up other codes in the denial code library.
Last reviewed by the Remitwright billing team. Editorial policy
Group PR means patient responsibility: the balance may be billed to the patient. The number is the reason; the two-letter group says who carries the balance.
Common causes
The plan year has just started
Deductibles reset with the plan year, often in January, and the first claims of the year carry the full allowed amount to the patient until the deductible is met. High-deductible plans keep this going for months.
The service is subject to the deductible
Plans exempt some services, typically preventive visits, and apply the deductible to others. A visit coded as problem-oriented because of the diagnoses or an added procedure can shift from exempt to deductible-applied.
An out-of-network deductible was applied
Plans carry separate, higher deductibles for out-of-network care. If the practice is not in network with the specific plan product on the card, the allowed amount falls into the out-of-network deductible and the patient's share is larger than they expected.
The payer has not yet counted claims from other providers
The patient may have met the deductible at a hospital or another office, but those claims were processed after yours. The payer's accumulator was still open when your claim adjudicated.
Medicare Part B deductible with secondary coverage pending
Original Medicare applies its Part B deductible each year. A patient with Medigap or Medicaid as secondary often has that amount picked up, but only once the secondary claim is processed, through crossover or by direct submission.
How to fix it and resubmit
- 1
Post the 835 exactly as adjudicated
Record the allowed amount, the contractual adjustment (usually CO-45) and the PR-1 amount as the patient balance. The patient owes the allowed amount applied to the deductible, not the difference between your charge and the payment.
- 2
Bill any secondary plan before the patient
Check the patient record and the eligibility response for a secondary payer. Send the secondary claim with the primary's adjudication, or confirm the crossover went through for Medicare patients, and bill the patient only what the secondary leaves.
- 3
Check QMB status on every Medicare patient
Federal law prohibits Medicare providers and suppliers from billing people in the Qualified Medicare Beneficiary group for Medicare cost sharing, and the remittance advice carries QMB information. Bill the state Medicaid program as its rules allow, and send no statement to the patient.
- 4
Send the statement promptly with a plain explanation
A statement that arrives weeks after the visit, with no reference to the EOB, gets ignored. Show the allowed amount, the payer's payment and the deductible applied, and give the patient the payment options your practice offers.
- 5
Query the payer when the deductible looks wrong
If the patient has proof the deductible was already met, or an in-network deductible should have applied, call the payer with the accumulator details and ask for reprocessing. This is a reprocessing request, not an appeal.
How to prevent it
- Eligibility verification before each visit that returns the deductible remaining, so the front desk can collect an estimate at the time of service where the contract allows it
- A written financial policy that explains deductibles and payment options, signed at intake, with a card on file where the practice uses one
- Network status checked per plan product, not per insurer name, before scheduling
- QMB indicator and secondary coverage checked on every Medicare eligibility response and flagged on the account before a statement can go out
A PR-1 on the first visit of the plan year
A family practice sees a patient with a high-deductible plan in the first week of January. The payer allows the visit, pays nothing, and returns the full allowed amount as PR-1 with the difference between the charge and the allowed amount as CO-45. The biller posts the contractual adjustment, moves the PR-1 amount, here the full allowed amount, to the patient balance, confirms from the eligibility response that there is no secondary plan, and sends a statement that week with the EOB figures on it. This is a hypothetical example.
Official text: the X12 claim adjustment reason code list. The meaning above is our paraphrase for billers; the list is the authority.
FAQ
Questions about PR-1
Do I bill the patient the full charge, the allowed amount or the PR-1 amount?
Can I waive the deductible for patients who cannot pay?
The patient has Medicare and Medicaid. Can I bill the deductible?
Do I need an ABN to collect the Medicare deductible?
Should PR-1 go to denial management?
Next step
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While you wait: see the sample weekly report or read how to work claim denials. You can also download the sample weekly report (PDF).