PR-90: Ingredient Cost Adjustment
The patient owes this ingredient cost adjustment. Verify the balance and collect from the patient.
What Does PR-90 Mean?
With PR (Patient Responsibility), the ingredient cost adjustment 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 the patient requested a brand-name medication when a generic equivalent is covered, and the cost difference between brand and generic ingredient costs is the patient's responsibility.
CARC 90 means the payer adjusted the payment based on ingredient cost adjustment. 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 pharmacy or provider billed an ingredient cost higher than the payer's MAC pricing list, and the payer adjusted the payment down to the MAC rate; The billed ingredient cost was based on a different pricing benchmark than the payer uses, such as AWP vs. ASP (Average Sales Price), resulting in a downward adjustment; A generic equivalent is available at a lower ingredient cost, and the payer adjusted the payment to the generic pricing level per formulary rules. The group code paired with CARC 90 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.
Common Causes
| Cause | Frequency |
|---|---|
| Patient chose brand-name drug when generic is available The patient requested a brand-name medication when a generic equivalent is covered, and the cost difference between brand and generic ingredient costs is the patient's responsibility | Most Common |
| Non-formulary drug ingredient cost excess The prescribed medication is not on the payer's formulary, and the patient is responsible for the difference between the billed ingredient cost and the formulary tier allowance | Common |
How to Resolve
- Verify the ingredient cost adjustment Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the ingredient cost adjustment 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 ingredient cost adjustment, 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.
This adjustment correctly assigns the ingredient cost difference to the patient per formulary rules. The patient chose a brand-name or non-formulary medication. Collect from the patient rather than appealing.
How to Prevent PR-90
- Inform patients about formulary options and generic alternatives before dispensing
- Provide cost estimates to patients for brand-name vs. generic medications
- Use payer formulary lookup tools to identify the most cost-effective drug options for patients
Also Filed As
The same CARC 90 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.cms.gov/medicare/payment/part-b-drugs/average-sales-price
- https://www.aapc.com/resources/claim-adjustment-reason-code-carc
- https://www.mdclarity.com/denial-code/90
- Codes maintained by X12. Visit x12.org for official definitions.