PR-2: Coinsurance Amount
PR (Patient Responsibility)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.
Altair catches PR-2 denials before submission with patient responsibility estimation. See how pre-submit claim scoring works.