PR-102: Major Medical Adjustment
The patient owes this major medical adjustment. Verify the balance and collect from the patient.
What Does PR-102 Mean?
With PR (Patient Responsibility), the major medical adjustment is the patient's financial obligation. The insurer processed the claim, applied the patient's plan benefits, and this amount is owed directly by the patient. The most common scenario is the patient owes the major medical copay, coinsurance, or deductible amount under their plan's major medical benefit tier.
CARC 102 means the payer adjusted the payment based on major medical adjustment. The reimbursement was calculated using the payer's fee schedule, contracted rate, or regulatory payment methodology rather than the billed charge.
Common scenarios that trigger this adjustment include: the patient's major medical benefit has a specific allowance or calculation methodology, and CARC 102 reflects the adjustment between billed charges and the major medical allowed amount; The major medical portion of the plan applies its own deductible and coinsurance schedule, which differs from the basic medical benefit, resulting in an adjustment; The service is classified under the major medical benefit rather than basic medical coverage, resulting in different payment rules and a corresponding adjustment. The group code paired with CARC 102 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.
Common Causes
| Cause | Frequency |
|---|---|
| Patient's major medical cost-sharing responsibility The patient owes the major medical copay, coinsurance, or deductible amount under their plan's major medical benefit tier | Most Common |
| Major medical out-of-pocket maximum not yet met The patient has not reached their major medical out-of-pocket maximum and is responsible for the applicable cost-sharing | Common |
How to Resolve
- Verify the major medical adjustment Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the major medical adjustment was applied correctly per plan terms.
- Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
- Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the major medical adjustment, and the balance the patient owes.
- Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
- Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
This is a standard patient cost-sharing obligation under the major medical benefit tier. The claim was processed correctly. Collect from the patient.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-102:
| RARC | Description |
|---|---|
| N381 | This amount reflects the patient's responsibility under the major medical benefit tier Verify the patient's major medical deductible and coinsurance status → |
How to Prevent PR-102
- Inform patients of their major medical cost-sharing obligations at the time of service
- Provide cost estimates that reflect the major medical benefit tier's deductible and coinsurance
- Collect estimated major medical cost-sharing amounts at the point of service
Also Filed As
The same CARC 102 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.cms.gov/medicare/payment/fee-schedules
- https://www.aapc.com/resources/claim-adjustment-reason-code-carc
- https://www.mdclarity.com/denial-code/102
- Codes maintained by X12. Visit x12.org for official definitions.