PR-1: Deductible Amount Not Met
PR (Patient Responsibility)What is PR-1?
PR-1 is a Patient Responsibility code indicating the billed amount (or a portion) was applied to the patient's annual deductible. This is not a denial in the traditional sense. The payer processed the claim correctly but transferred the balance to the patient because their deductible has not been satisfied.
Why Does PR-1 Occur?
- Patient has not met their annual deductible. The service was rendered early in the plan year or the patient has a high-deductible health plan (HDHP).
- Deductible reset at plan renewal. The patient's plan year reset and the deductible restarted, even if it was met in the prior year.
- Service type subject to separate deductible. Some plans have separate deductibles for pharmacy, mental health, or out-of-network services.
How to Fix PR-1 Denials
- Verify the deductible amount and how much has been met by checking the patient's eligibility in real time or on the payer portal.
- Bill the patient for the amount applied to the deductible. Include a clear explanation on the patient statement showing the payer's adjudication.
- If the deductible amount seems incorrect, compare the payer's EOB to the patient's plan documents and file a dispute if the calculation is wrong.
- For future visits, verify deductible status before the appointment so the patient knows their expected out-of-pocket cost.
PR-1 by Payer
| Payer | Common RARC | Appeal Deadline | Notes |
|---|---|---|---|
| UnitedHealthcare | N/A | 60 days from remittance | UHC HDHPs are common. Verify deductible status in real time on the portal. |
| Anthem | N/A | 365 days from denial notice | Anthem plans may have separate in-network and OON deductibles. |
| Aetna | N/A | 180 days from denial | Aetna's eligibility API provides real-time deductible accumulator data. |
| Cigna | N/A | 180 days from denial | Cigna reports deductible status on the 271 eligibility response. |
| Medicare | N/A | 120 days (redetermination at MAC) | Medicare Part B deductible is $257 (2026). Check beneficiary status for the year. |
Related CARC Codes
If you are seeing PR-1, check these related codes: PR-2 (coinsurance), PR-3 (copay), PR-96 (non-covered charge).
Common Questions About PR-1
Is PR-1 a denial?
No. PR-1 is a patient responsibility adjustment, not a payer denial. The payer processed the claim and applied the charge to the patient's deductible. The provider collects this amount from the patient.
How do I collect deductible amounts from patients?
Send a patient statement showing the payer's adjudication, the deductible amount applied, and the balance due. Collect at time of service when possible by verifying deductible status before the appointment.
Altair catches PR-1 denials before submission with real-time eligibility verification. See how pre-submit claim scoring works.