CARC 100 Active

PR-100: Payment Made to Patient/Insured

TL;DR

Patient responsibility — review the adjustment and determine if the patient truly owes this amount.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-100 Mean?

With PR (Patient Responsibility), the CARC 100 adjustment for payment made to patient/insured shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

CARC 100 appears on a remittance when the payer applies an adjustment for payment made to patient/insured. Review the group code and any accompanying RARC codes to understand the full context of this adjustment.

Common scenarios that trigger this adjustment include: the provider did not accept assignment on the claim, so the payer sent the payment directly to the patient or insured per non-assigned billing rules; The patient submitted the claim to their insurance company for reimbursement, and the payer issued payment to the patient rather than the provider; The provider is out of network, and the payer's policy is to reimburse the member directly for out-of-network services rather than paying the provider. The group code paired with CARC 100 determines who bears the financial responsibility — OA indicates a coordination of benefits or other payer adjustment, CO places it on the provider as a contractual obligation, PR shifts it to the patient.

How to Resolve

  1. Review the adjustment Examine the PR-100 adjustment and any RARC codes to understand the basis for the patient responsibility.
  2. Verify the adjustment is correct Confirm the PR designation and amount are appropriate based on the patient's plan benefits.
  3. Appeal if incorrect If the adjustment appears incorrect, file an appeal with supporting documentation.
  4. Collect from the patient if valid If the adjustment is confirmed correct, generate a patient statement and follow standard collection procedures.
Do Not Appeal This Code

Payment Made to Patient/Insured grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

How to Prevent PR-100

Also Filed As

The same CARC 100 may appear with different Group Codes:

OA-100 CO-100

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

Sources

  1. https://www.cms.gov/medicare/claims-appeals/organization-determinations
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/100
  4. Codes maintained by X12. Visit x12.org for official definitions.