PR-248: Professional Service Coinsurance on Institutional Claim

What Does PR-248 Mean?

PR-248 confirms the coinsurance amount for the professional service component is the patient's financial responsibility. The payer has calculated the coinsurance based on the patient's plan design and the allowed amount for the professional service. This is standard cost-sharing under the patient's benefit plan, not a coverage denial or billing error.

CARC 248 appears when a payer processes an institutional claim and calculates the patient's coinsurance obligation for the professional service component. Like its companion code CARC 247 (which handles deductibles), CARC 248 specifically isolates the coinsurance portion attributable to the professional service on a facility claim, allowing proper allocation of patient cost-sharing.

This is a patient responsibility determination, not a denial. The payer has adjudicated the claim and determined that the patient owes a coinsurance percentage of the allowed amount for the professional service. The code appears with Group Code PR, confirming the patient is financially responsible for this amount.

Providers see CARC 248 when professional services are billed within institutional settings — hospital outpatient departments, skilled nursing facilities, or other facility-based care. The coinsurance rate depends on the patient's specific benefit plan. The primary action is to verify the coinsurance calculation is correct, ensure there is no duplicate coinsurance application between facility and professional claims, and collect the verified amount from the patient.

Common Causes

How to Resolve

Verify the coinsurance rate and amount are correct based on the patient's benefit plan, then collect the coinsurance from the patient.

1. Validate the coinsurance calculation Verify the coinsurance percentage matches the patient's benefit plan for professional services in institutional settings. Calculate whether the applied amount is correct based on the allowed amount and the plan's coinsurance rate.
2. Cross-reference other claims Check whether the same professional service was also billed on a CMS-1500 with a separate coinsurance application. Prevent duplicate patient billing across claim types.
3. Issue patient statement Bill the patient for the verified coinsurance amount with clear identification of the date of service, service rendered, and coinsurance percentage applied.
4. Dispute incorrect calculations If the coinsurance rate or amount is incorrect, contact the payer with benefit verification documentation and request reprocessing of the claim with the correct coinsurance rate.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-248:

How to Prevent PR-248

• Verify the patient's coinsurance obligations before rendering services in institutional settings to provide accurate cost estimates
• Ensure correct claim form usage per payer requirements — bill professional services on CMS-1500 and institutional services on UB-04 to prevent cost-sharing allocation issues
• Coordinate between facility and professional billing teams to prevent duplicate coinsurance application across claim types
• Verify patient benefits and applicable coinsurance rates at registration, particularly for services with variable cost-sharing in institutional versus office settings
• Train billing staff on proper handling of professional service components on institutional claims to prevent cost-sharing errors

General Prevention

• Ensure proper claim form selection per payer requirements — bill professional services on CMS-1500 and institutional services on UB-04
• Coordinate between facility and professional billing departments to prevent double-application of coinsurance on split-billed services
• Verify patient benefits and confirm the applicable coinsurance rate for professional services provided in institutional settings before claim submission
• Train billing staff on proper handling of professional service components on institutional claims

Related Denial Codes