CARC 45 Active

PR-45: Charge Exceeds Fee Schedule/Maximum Allowable

TL;DR

The patient is responsible for this adjustment amount. Verify the balance and collect from the patient.

Action
Collect from Patient
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-45 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 45 is owed by the patient. The payer determined that this portion — related to charge exceeds fee schedule/maximum allowable — falls under the patient's financial obligation per their plan benefits.

CARC 45 means the payer adjusted the payment based on charge exceeds fee schedule/maximum allowable. The reimbursement was calculated using the payer's fee schedule, contracted rate, or regulatory payment methodology rather than the billed charge.

Common scenarios that trigger this adjustment include: the provider's charge exceeds the contracted fee schedule rate with the payer; Charges exceed the Medicare Physician Fee Schedule (MPFS) allowed amount; The billed amount is higher than the payer's maximum allowable for the service. The group code paired with CARC 45 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

Cause Frequency
Non-participating provider balance billing Out-of-network provider can balance bill the patient for charges above the allowable amount Most Common
Plan design with balance billing Plan allows balance billing to the patient for amounts exceeding the fee schedule Common

How to Resolve

  1. Verify the adjusted amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the adjustment amount was applied correctly per plan terms.
  2. Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
  3. Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the adjustment amount, and the balance the patient owes.
  4. Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
  5. Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
Do Not Appeal This Code

PR-45 reflects the patient's financial responsibility for charges above the payer's fee schedule. For in-network providers, this amount is a contractual adjustment absorbed by the provider. For out-of-network, it may be balance billed to the patient.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-45:

RARC Description
N14 Payment based on contractual amount or fee schedule Determine if balance billing is permitted →
N381 Consult contract for payment information Review balance billing rights under the contract →

How to Prevent PR-45

Also Filed As

The same CARC 45 may appear with different Group Codes:

CO-45 OA-45

Related Denial Codes

PR-2 — Coinsurance Amount PR-3 — Co-payment Amount PR-1 — Deductible Amount PR-4 — Procedure Code Inconsistent with Modifier PR-5 — Procedure Code Inconsistent with Place of Service

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/45
  3. https://www.athelas.com/tbh/decoding-carc-code-45-navigating-fee-schedule-denials-in-medical-billing
  4. https://cms.officeally.com/blog/understanding-claim-response-codes-co-45-and-n381
  5. Codes maintained by X12. Visit x12.org for official definitions.