PR-245: Provider Performance Program Withhold

What Does PR-245 Mean?

CARC 245 indicates that the payer is withholding a portion of the claim payment as part of a provider performance program established in your contract. This is not a denial or an error — it is a contractual mechanism where the payer sets aside a percentage of each payment, with the potential to return some or all of the withheld amount based on your performance on quality metrics.

These programs go by various names: pay-for-performance, value-based payment arrangements, shared savings programs, and risk-sharing agreements. The common thread is that the payer holds back a defined percentage and ties its return to measurable outcomes such as patient satisfaction scores, readmission rates, preventive care compliance, or cost efficiency targets.

The withheld amount is not lost revenue — it is contingent revenue. Providers who meet or exceed the performance targets may receive the full withhold back, and in some programs, earn additional incentive payments. Providers who fall short of targets may forfeit part or all of the withheld amount.

How to Resolve

Verify the withhold amount against your contract terms, track your performance metrics, and contact provider relations if the calculation appears incorrect.

1. Review your payer contract Locate the performance program withhold provisions in your contract. Confirm the withhold percentage, the specific quality metrics used for evaluation, the performance period dates, and the conditions for withhold return.
2. Verify the withhold calculation Compare the withheld amount on the remittance against the contracted withhold percentage applied to the allowed amount. Ensure the math is correct and consistent across claims.
3. Track withheld amounts Maintain a running total of all withheld amounts for each performance period. This helps you monitor your financial exposure and reconcile when the withhold is returned.
4. Monitor your quality metrics Actively track your performance on the quality measures tied to the withhold program. Most payers provide periodic reports showing your standing against the targets.
5. Contact provider relations if needed If the withhold percentage exceeds what your contract specifies, or if the calculation appears incorrect, contact the payer's provider relations department with your contract and payment documentation.

Also Filed As

The same CARC 245 may appear with different Group Codes:

Related Denial Codes