Denial code · group PR
PR-2: The patient owes a share of the allowed amount as coinsurance
Short answer
PR-2 means the payer paid its share of the allowed amount and left the patient's coinsurance for the practice to collect. It is the expected result on a paid claim, not a denial. Bill the patient the PR-2 amount, or bill a secondary plan first if there is one. For Medicare patients check QMB status before any statement goes out, because federal law bars billing them for Medicare cost sharing.
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 design splits the allowed amount after the deductible
Once the deductible is met, most plans pay a set share of the allowed amount and leave the rest to the patient. The share varies by service tier, so a diagnostic test and an office visit on the same day can carry different coinsurance amounts.
Original Medicare Part B leaves a coinsurance share on most services
After the Part B deductible, Medicare pays its share of the approved amount and the beneficiary owes the rest. Patients with Medigap or Medicaid as secondary usually have that share covered once the secondary claim is processed.
An out-of-network share was applied
Out-of-network coinsurance is higher, and the plan's allowed amount may be lower than your charge. What can be billed beyond the PR-2 amount depends on the federal and state balance billing rules for the service and setting.
The secondary plan was not on file
The patient has a spouse's plan or Medicaid behind the primary, but the registration record shows only one payer. The PR-2 amount goes straight to a statement when it should have gone to the secondary.
The payer applied coinsurance where the benefit says copay
Plan setups are not always loaded correctly at the payer. A visit the benefit summary lists as a flat copay can adjudicate with a percentage share instead. The patient notices before you do.
How to fix it and resubmit
- 1
Post the 835 and check the arithmetic
Allowed amount minus the payer's payment minus any other adjustments should equal the PR-2 amount plus any other patient responsibility codes. If it does not, the remittance has an adjustment you have not accounted for.
- 2
Bill the secondary plan with the primary's adjudication
Send the secondary claim with the primary's allowed, paid and adjustment data in the COB loops. For Medicare patients with Medigap, confirm the crossover; if it did not occur, bill the Medigap plan directly. Medicaid as secondary follows state rules on what it pays and what the patient can be charged.
- 3
Check QMB status before the statement
The Medicare remittance advice carries QMB information. A patient in that group cannot be billed for Medicare coinsurance; bill the state Medicaid program instead under its rules, and stop any statement already queued.
- 4
Send a statement that explains the share
Show the allowed amount, the payer's payment and the coinsurance share. Patients pay faster when the statement matches the EOB they already received.
- 5
Ask for reprocessing when the share does not match the benefit
If the plan's benefit summary says a copay and the 835 shows coinsurance, or the in-network share was applied as out-of-network, call the payer with the plan documents and ask for reprocessing. Do not bill the patient the disputed amount while the payer reviews it.
How to prevent it
- Eligibility verification that returns coinsurance by service type, so the time-of-service estimate reflects what the plan will actually leave to the patient
- Secondary coverage asked for and recorded at every registration, including Medicaid and Medigap for Medicare patients
- Network participation confirmed per plan product before scheduling, so out-of-network shares are not a surprise to the patient or the practice
- QMB information reviewed on every Medicare remittance before patient balances are released to statements
A PR-2 with a secondary commercial plan on file
A cardiology practice bills a diagnostic test for a patient whose deductible is already met. The 835 shows the allowed amount, the payer's payment and the remaining share as PR-2. The patient also has a secondary commercial plan through a spouse. The biller posts the primary payment, sends the secondary claim with the primary's adjudication data, and bills the patient only the amount the secondary leaves, which in this case is nothing. 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-2
Is PR-2 a denial I need to appeal?
Can I collect coinsurance at the time of service?
The patient says they already paid their coinsurance. What do I check?
Can I bill a Medicare patient with Medicaid for the coinsurance?
Out of network, can I bill the patient the difference between my charge and the allowed amount?
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