Denial code · group PR
PR-3: The patient's fixed copayment for the visit or service is due from the patient
Short answer
PR-3 means the payer subtracted the patient's copayment from the allowed amount and expects the practice to collect it. Most offices take the copay at check-in, so the real job is reconciling the 835 amount against what the front desk collected. Bill the patient for any gap, refund any excess, and never bill a Medicare patient in the Qualified Medicare Beneficiary group for a copay.
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 copay was not collected at the visit
Telehealth visits, walk-ins during a rush, a declined card or a front desk that waived it for a regular patient. The 835 arrives with PR-3 and nothing on the account to match it.
The wrong copay tier was collected
Cards show a primary care copay and a specialist copay, and sometimes an urgent care copay. Collecting the primary care amount for a specialist visit, or the office amount for an urgent care visit, leaves the difference on the account.
The visit the front desk treated as preventive adjudicated as a problem visit
The patient came for a wellness visit and expected no copay. A problem addressed during the visit, or a diagnosis order that puts a problem code first, makes the payer apply the office visit copay.
More than one copay applied on the same day
A visit plus a procedure, or a visit at one location and a test at another, can each carry a copay under some plans. The front desk collected one; the 835 shows two.
The plan changed the copay and the card is out of date
Plan years bring new copay amounts, and patients keep old cards. The eligibility response has the current amount; the card does not.
How to fix it and resubmit
- 1
Reconcile the PR-3 amount against time-of-service payments
Match the copay on the 835 to the payment posted for that date of service. Equal means the balance is zero. Short means a statement; over means a refund or a credit the patient agrees to apply.
- 2
Bill the gap on a statement that names the visit
A statement line that says which visit the copay belongs to, and that the plan requires it, gets paid. A bare balance with no explanation gets a phone call or nothing.
- 3
Check for secondary coverage that pays copays
Medicaid as a secondary plan and some supplemental plans cover copays. Bill them with the primary's adjudication before billing the patient.
- 4
Confirm QMB status before any Medicare copay statement
A Medicare patient in the Qualified Medicare Beneficiary group cannot be billed for Medicare cost sharing; federal law prohibits it and the remittance identifies QMB status. Bill the state Medicaid program under its rules.
- 5
Review the coding when a preventive visit drew a copay
If the visit was genuinely preventive and the claim was coded as a problem visit, a corrected claim fixes the copay. If a problem was addressed and documented, the copay is correct and the patient needs an explanation, not a refund.
How to prevent it
- Eligibility verification that returns the copay by visit type, used at check-in instead of the amount printed on the card
- A card-on-file or payment link process for telehealth and for any visit where the copay was not collected at check-in
- A front desk script that explains to patients how a preventive visit becomes a problem visit when a new complaint is addressed
- Copay collection reports reviewed weekly so visits that left without a copay are followed up while the visit is still fresh
A PR-3 on a telehealth visit with no copay taken
An urgent care center completes a telehealth visit and nobody collects the copay before the call ends. The 835 arrives with the payer's payment and the copay as PR-3. The biller matches the visit, finds no payment, and sends a statement that names the visit date and the plan copay. The center adds a payment link to the telehealth check-in so the copay is collected before the clinician joins. 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-3
Can I waive copays for patients who cannot afford them?
Why is the PR-3 amount different from the copay on the card?
The patient came for a preventive visit. Why was a copay applied?
Can I bill a Medicare copay to a patient who also has Medicaid?
Is it right for two copays to apply on one day?
Next step
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