PR-101: Predetermination: Anticipated Payment

What Does PR-101 Mean?

With PR (Patient Responsibility), the CARC 101 adjustment for predetermination: anticipated payment 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 101 appears on a remittance when the payer applies an adjustment for predetermination: anticipated payment. 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 submitted a predetermination request, and CARC 101 on the response indicates the estimated payment amount the payer expects to pay when the actual claim is submitted. This is not a denial.; The anticipated payment on the predetermination is lower than the provider expected, possibly due to fee schedule rates, benefit limitations, or coverage restrictions identified during the predetermination review; The predetermination was obtained but the service was not rendered within the validity period, so the anticipated payment no longer applies and a new predetermination may be needed. The group code paired with CARC 101 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

How to Resolve

1. Review the adjustment Examine the PR-101 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.

How to Prevent PR-101

• Verify patient benefits and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively

Also Filed As

The same CARC 101 may appear with different Group Codes:

Related Denial Codes