PR-2: Coinsurance Amount
The patient owes this coinsurance amount. Verify the balance and collect from the patient.
What Does PR-2 Mean?
With PR (Patient Responsibility), the coinsurance amount 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 patient's plan requires a percentage cost-sharing for covered services after deductible is met.
CARC 2 appears on a remittance when the payer adjusts payment for the coinsurance amount. This is a standard plan-defined cost-sharing amount that the patient is obligated to pay per their insurance benefits. The code confirms the payer processed the claim correctly and applied the plan's benefit structure as designed.
Common scenarios that trigger this adjustment include: patient's plan requires a percentage cost-sharing for covered services after deductible is met; Higher coinsurance percentage applied for services from out-of-network providers; Specific service categories carry different coinsurance rates per the plan design. The group code paired with CARC 2 determines who bears the financial responsibility — PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment, CO places it on the provider as a contractual obligation.
Common Causes
| Cause | Frequency |
|---|---|
| Standard coinsurance obligation Patient's plan requires a percentage cost-sharing for covered services after deductible is met | Most Common |
| Out-of-network coinsurance rate Higher coinsurance percentage applied for services from out-of-network providers | Common |
| Plan benefit structure Specific service categories carry different coinsurance rates per the plan design | Common |
| Out-of-pocket maximum not yet reached Patient has not reached their out-of-pocket maximum, so coinsurance still applies | Common |
How to Resolve
- Verify the coinsurance amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the coinsurance amount 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 coinsurance amount, 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.
Coinsurance amounts are a contractual patient cost-sharing obligation defined by the insurance plan. The adjustment reflects correct application of plan benefits.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-2:
| RARC | Description |
|---|---|
| N381 | Consult contract/fee schedule for payment information Review the patient's plan details for coinsurance percentage → |
| N14 | Payment based on a contractual amount or agreement Verify the allowed amount used for coinsurance calculation → |
How to Prevent PR-2
- Verify insurance eligibility and coinsurance rates before services
- Educate patients about their coinsurance obligations at check-in
- Collect estimated coinsurance at time of service
- Use real-time eligibility tools to determine benefit details
- Implement accurate coding practices with regular audits
Also Filed As
The same CARC 2 may appear with different Group Codes: