PR-3: Co-payment Amount
The patient owes this co-payment amount. Verify the balance and collect from the patient.
What Does PR-3 Mean?
With PR (Patient Responsibility), the co-payment 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 fixed co-payment amount for office visits and other services.
CARC 3 appears on a remittance when the payer adjusts payment for the co-payment 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 fixed co-payment amount for office visits and other services; Higher co-payment required for specialist visits versus primary care; ER visits carry a higher co-payment per the patient's plan. The group code paired with CARC 3 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 office visit co-pay Patient's plan requires a fixed co-payment amount for office visits and other services | Most Common |
| Specialist co-pay applied Higher co-payment required for specialist visits versus primary care | Common |
| Emergency room co-pay ER visits carry a higher co-payment per the patient's plan | Common |
| Prescription co-pay tier Different co-payment tiers apply based on medication formulary placement | Occasional |
How to Resolve
- Verify the co-payment amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the co-payment 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 co-payment 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.
Co-payment amounts are a contractual patient 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-3:
| RARC | Description |
|---|---|
| N381 | Consult contract/fee schedule for payment information Review the patient's plan for co-payment schedule → |
| N14 | Payment based on a contractual amount or agreement Verify the co-pay amount per the plan contract → |
How to Prevent PR-3
- Collect co-payments at time of service before the visit
- Verify co-payment amounts during eligibility verification
- Post co-payment schedules at the front desk for common plan types
- Use real-time eligibility tools to confirm exact co-pay amounts
- Train front desk staff on collecting appropriate co-payments
Also Filed As
The same CARC 3 may appear with different Group Codes: