PR-248: Coinsurance for Professional Service in Institutional Setting
PR-248 is the patient's coinsurance for a professional service in a bundled payment episode. Verify the rate and collect from the patient.
What Does PR-248 Mean?
When paired with Group Code PR, the coinsurance is the patient's financial responsibility under their Medicare cost-sharing obligations. This is the expected and standard group code for CARC 248.
CARC 248 identifies the patient's coinsurance obligation for a professional service provided in an institutional setting and billed on an institutional claim under a Medicare bundled payment program (PPACA). This is the coinsurance counterpart to CARC 247, which handles the deductible portion.
Under Medicare bundled payment arrangements such as BPCI, a single payment covers the entire episode of care. The patient's standard coinsurance obligation — typically 20% under Medicare Part B — still applies to the professional service component. CARC 248 isolates this coinsurance amount so the provider can collect the correct patient responsibility.
This code appears exclusively in Medicare bundled payment contexts. The coinsurance percentage follows standard Medicare Part B rules unless the bundled payment arrangement specifies otherwise.
Common Causes
| Cause | Frequency |
|---|---|
| Medicare bundled payment coinsurance application Under Medicare's BPCI or other bundled payment programs, the coinsurance for professional services rendered in an institutional setting is applied to the patient | Most Common |
| Professional component coinsurance on institutional claim The professional component of a service billed on an institutional claim triggers a coinsurance amount assigned to the patient | Common |
| Patient coinsurance per Medicare Part B The standard Medicare Part B coinsurance (typically 20%) is applied to the professional portion of services in the bundled episode | Common |
How to Resolve
- Verify coinsurance accuracy Confirm the coinsurance rate and dollar amount are correct based on the allowed amount and the patient's Medicare Part B coinsurance percentage.
- Confirm bundled payment context Verify the claim is within a Medicare bundled payment episode.
- Issue patient statement Send the patient a clear statement showing the coinsurance owed for the professional service.
- Contact MAC if incorrect If the coinsurance amount does not match the expected calculation, contact the Medicare contractor for verification.
This is the patient's coinsurance for a professional service rendered in an institutional setting under a Medicare bundled payment program. Coinsurance is a standard patient cost-sharing obligation. Collect from the patient.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-248:
| RARC | Description |
|---|---|
| N130 | Consult plan benefit documents/guidelines for coverage of this service. Review the bundled payment program guidelines for coinsurance application rules → |
How to Prevent PR-248
- Estimate patient coinsurance obligations before providing services in bundled payment episodes to set expectations
- Inform patients about coinsurance for professional services in institutional settings during pre-service discussions
- Collect estimated coinsurance at the time of service when feasible to reduce accounts receivable
General Prevention
- Estimate patient coinsurance obligations before services in bundled payment episodes
- Inform patients about coinsurance for professional services in institutional settings
- Collect coinsurance at the time of service when possible
Also Filed As
The same CARC 248 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
- https://www.aapc.com/resources/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.