PR-102: Major Medical Adjustment

What Does PR-102 Mean?

PR-102 assigns the major medical cost-sharing to the patient. This typically includes the major medical deductible (if not yet met), coinsurance at the major medical rate, or amounts exceeding plan limits for the major medical category. The patient is financially responsible for this amount and should be billed accordingly.

CARC 102 surfaces when the payer adjudicates your claim under the major medical benefit tier of the patient's plan and applies an adjustment based on that tier's specific coverage rules. Many insurance plans divide benefits into tiers — basic and major medical — with different deductibles, coinsurance rates, and coverage limits for each. When a service falls under the major medical tier, the financial rules can differ significantly from basic benefits.

This code is particularly relevant for plans that maintain separate deductible and out-of-pocket accumulations for major medical services. A patient might have a fully satisfied basic deductible but still have an unmet major medical deductible, causing charges to be applied differently depending on the benefit category. The payer uses CARC 102 to signal that the adjustment is specifically a major medical benefit calculation, not a standard fee schedule reduction or coverage denial.

From a billing perspective, the first step is always to verify that the service was correctly categorized. Coding errors can cause a service to be adjudicated under the wrong benefit tier — for example, a procedure that should fall under basic benefits might be classified as major medical due to an incorrect CPT code or missing modifier. If the categorization is correct, the adjustment is a legitimate application of the plan's benefit structure, and your response depends on the group code: write off the CO portion and collect the PR portion from the patient.

Common Causes

How to Resolve

Verify the service was categorized under the correct benefit tier, then post the contractual adjustment and bill the patient for their major medical cost-sharing.

1. Verify the patient's major medical cost-sharing Confirm the patient's current major medical deductible status and coinsurance rate. Verify the PR-102 amount matches what the patient should owe based on their plan.
2. Transfer to patient A/R Move the PR-102 amount to the patient responsibility ledger and generate a detailed statement showing the service, the major medical adjustment, and the patient's obligation.
3. Explain the major medical benefit structure Contact the patient to explain that their plan has a separate major medical benefit tier with its own deductible and coinsurance. Provide the specific amount owed.
4. Offer payment arrangements Major medical cost-sharing amounts can be substantial. Offer payment plans and multiple payment methods to improve collectability.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-102:

How to Prevent PR-102

• Inform patients about their major medical benefit structure including deductibles and coinsurance before rendering high-cost services
• Collect estimated patient responsibility at the time of service based on the major medical benefit tier
• Use patient cost estimation tools that account for the separate major medical deductible and coinsurance rates

General Prevention

• Verify the patient's benefit structure before rendering services, paying attention to whether the service falls under basic or major medical benefits
• Obtain prior authorization for services that fall under the major medical benefit tier when required by the payer
• Use accurate procedure and diagnosis codes to ensure claims are adjudicated under the correct benefit category
• Check the patient's remaining major medical benefits and maximums before scheduling services
• Educate patients about their major medical benefit structure, including deductibles, coinsurance, and maximums, before services are rendered
• Monitor claim remittances for patterns of major medical adjustments to identify systemic coding or billing issues

Also Filed As

The same CARC 102 may appear with different Group Codes:

Related Denial Codes