What is PR-2?
PR-2 is a Patient Responsibility code indicating the patient owes a coinsurance percentage of the allowed amount after the payer has paid its share. Coinsurance is the patient's percentage responsibility (typically 20-40%) of the allowed amount after deductible is met.
Why Does PR-2 Occur?
- Standard plan coinsurance applies. The patient's plan requires a percentage copay (e.g., 20%) of the allowed amount after deductible.
- Out-of-network coinsurance rate applied. The patient saw an OON provider, triggering a higher coinsurance percentage (e.g., 40% instead of 20%).
- Service category with different coinsurance. Some plans have higher coinsurance for specialist visits, surgery, or imaging.
How to Fix PR-2 Denials
- Verify the coinsurance percentage against the patient's plan. Confirm the payer applied the correct in-network or out-of-network rate.
- Calculate the expected coinsurance: Allowed Amount x Coinsurance Percentage = Patient Responsibility.
- If the coinsurance amount is incorrect, compare the EOB to the plan's Summary of Benefits and file a dispute with the payer.
- Bill the patient for the coinsurance amount with a clear breakdown on the statement.
PR-2 by Payer
| Payer | Common RARC | Appeal Deadline | Notes |
|---|---|---|---|
| UnitedHealthcare | N/A | 60 days from remittance | UHC coinsurance varies widely by plan. Check the 271 response for the exact percentage. |
| Anthem | N/A | 365 days from denial notice | Anthem's coinsurance may differ by service category (office vs. outpatient surgery). |
| Aetna | N/A | 180 days from denial | Aetna displays coinsurance details in the eligibility response. |
| Cigna | N/A | 180 days from denial | Cigna's tiered plans may apply different coinsurance for preferred vs. non-preferred providers. |
| Medicare | N/A | 120 days (redetermination at MAC) | Medicare Part B coinsurance is 20% of the Medicare-approved amount after deductible. |
Related CARC Codes
If you are seeing PR-2, check these related codes: PR-1 (deductible), PR-3 (copay), PR-96 (non-covered charge).
Common Questions About PR-2
What is the difference between coinsurance and copay?
Coinsurance is a percentage of the allowed amount (e.g., 20% of $200 = $40). A copay is a fixed dollar amount per visit (e.g., $25 per office visit). Both are patient responsibility.
Is PR-2 a denial?
No. PR-2 is the patient's share of the cost after the payer has processed the claim. The provider collects this amount from the patient.
Sources
The Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) definitions on this page follow the official code lists maintained by Accredited Standards Committee X12:
- Claim Adjustment Reason Codes (CARC), published by X12.
- Remittance Advice Remark Codes (RARC), published by X12.
Altair catches PR-2 denials before submission with patient responsibility estimation. See how pre-submission validation works.