PR-104: Managed Care Withhold

What Does PR-104 Mean?

With PR (Patient Responsibility), the CARC 104 adjustment for managed care withhold 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 104 means the payer adjusted the payment based on managed care withhold. 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 managed care contract includes a withhold provision where a percentage of each payment is retained by the payer and may be returned based on performance metrics or utilization targets; A portion of payment is withheld pending the provider meeting quality performance targets specified in the managed care agreement; The managed care plan withholds a percentage of payments that may be returned if the provider meets utilization benchmarks, such as reduced ER visits or referral rates. The group code paired with CARC 104 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-104 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-104

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

Also Filed As

The same CARC 104 may appear with different Group Codes:

Related Denial Codes