Denial codes · Denial code
PR-1, PR-2 and PR-3 on a nutrition claim: the patient owes, not a denial
By Javier Alvarez · Updated · 4 min read
| PR-1 | Deductible Amount |
|---|---|
| PR-2 | Coinsurance Amount |
| PR-3 | Co-payment Amount |
| Is it a denial? | No. The claim was processed and allowed. |
| Posting rule | Allowed = insurance paid + patient responsibility |
| Double-check when | Medicare MNT or preventive visits show cost-sharing |
A remit that says "paid $0" is alarming until you see PR-1 next to it. Then it is just a collection task. PR-1, PR-2 and PR-3 are the most common adjustment codes on nutrition claims, and none of them is a denial. They tell you the payer did its part and how much of the allowed amount belongs to the patient.
What PR-1, PR-2 and PR-3 mean
The X12 CARC list defines them in three words each:
| Code | Official description | What it means |
|---|---|---|
| PR-1 | "Deductible Amount" | The allowed amount (or part of it) went toward the patient's annual deductible. |
| PR-2 | "Coinsurance Amount" | The patient's percentage share after the deductible, for example 20% of the allowed amount. |
| PR-3 | "Co-payment Amount" | A flat amount per visit set by the plan. |
The group code PR means Patient Responsibility. The payer has assigned that amount to the patient, and you are allowed (and expected) to collect it.
Why a "paid" claim shows $0
Take an invented example: you bill $160 for a 60-minute 97803 follow-up (four units). The plan's allowed amount for four units under your contract is $112.
- Early in the year, deductible not met: CO-45 $48 (contractual write-off), PR-1 $112, paid $0. The patient owes you $112.
- Deductible met, 20% coinsurance: CO-45 $48, PR-2 $22.40, paid $89.60. The patient owes $22.40.
- Copay plan: CO-45 $48, PR-3 $30, paid $82. The patient owes $30.
In every case, billed = paid + CO + PR, and the patient owes exactly the PR amount. Nothing needs to be corrected or appealed. January through March are when PR-1 shows up most, because deductibles reset.
How to post and collect
- Post the payment line by line: insurance paid, contractual adjustment (CO-45) written off, PR amount moved to the patient's balance.
- Bill the PR amount, never the full charge. In network, the difference between your charge and the allowed amount is not collectible.
- Send a clear statement that names the visit date, the service and the plan's reason ("applied to your deductible").
- Collect copays at the visit when you know them. For deductibles, estimate from the benefits check and collect after the remit, or keep a card on file with the patient's written consent. Our guide on collecting copays in a nutrition practice has policies and scripts.
- Check the allowed amount against your contract. A PR code can hide an underpayment: if the allowed amount is lower than your fee schedule, the patient's share and the payer's share are both wrong. How to read an ERA/EOB shows the check.
When PR-1/2/3 is a sign of a routing mistake
Cost-sharing on a nutrition visit is normal for most commercial plans. It deserves a second look in two cases.
Medicare MNT should not have cost-sharing
Medicare says patients pay nothing for medical nutrition therapy services when the provider accepts assignment (Medicare.gov). If a Medicare line for 97802/97803 shows PR-1 or PR-2, check that it processed as MNT, that the diagnosis was a covered one, and whether the patient is actually in a Medicare Advantage plan with its own rules.
Preventive nutrition counseling processed as medical
Under the Affordable Care Act, most plans must cover certain preventive services without cost-sharing when delivered in network, including diet counseling for adults at higher risk for chronic disease (HealthCare.gov). Which nutrition visits qualify depends on each plan's preventive policy, and many policies route by the primary diagnosis. Cigna's A004 policy, for example, says preventive services submitted with diagnosis codes for treatment of illness are reviewed under the medical benefit, where deductibles and coinsurance apply.
So if you expected a preventive visit and got PR-1:
- Check the plan's preventive policy for nutrition counseling and the diagnoses it lists.
- Check your diagnosis order against what the visit actually was.
- Only resequence if the visit genuinely was preventive and the documentation supports it. If you treated a medical condition, the medical benefit (with cost-sharing) is correct, even if the patient is disappointed.
Our guide to preventive vs medical benefits walks through the decision.
PR codes that are not cost-sharing
Other PR codes mean something different. PR-204 means the service is not covered under the plan at all; PR-119 means the benefit maximum was reached. The patient is liable in both cases, but they are real non-payments, and the patient conversation is different. See the full list in the denial code lookup.
How to prevent surprise patient balances
- Quote the patient's share before the first visit: copay, remaining deductible, coinsurance, and whether nutrition counseling falls under preventive or medical benefits.
- Collect what you can at the visit and explain what may follow after the remit.
- Re-verify in January when deductibles reset and plans change.