Group code PR — Patient Responsibility
Patient owes this amount. Deductibles, coinsurance, copays, and excluded benefits land here.
Patient Responsibility (PR) is the part of the claim the patient owes. This includes the deductible, coinsurance, copay, amounts above the benefit limit, and excluded benefits. Patient responsibility is the line item that lands on a patient's EOB as 'You owe'. PR amounts can still be reduced by financial hardship programs, plan-specific subsidies, or HSA/FSA use.
How group code PR appears on your EOB
Every adjustment line on an insurance Explanation of Benefits (or 835 Electronic Remittance Advice) has a group code and at least one reason code (CARC). The group code is the “who”: PR means Patient Responsibility. The CARC is the “why”: a specific numeric reason like 50 (not medically necessary), 197 (prior auth absent), or 204 (not covered under benefit plan).
All four group codes
For context, the four X12 adjustment group codes are:
- CO — Contractual Obligation: Contractual write-off. The provider agreed to the rate. Patient does NOT owe this amount.
- PR — Patient Responsibility: Patient owes this amount. Deductibles, coinsurance, copays, and excluded benefits land here.
- OA — Other Adjustment: Informational or coordination-related adjustment. Usually means another payer is involved or there's a non-claim-related accounting entry.
- PI — Payer Initiated Reductions: Payer reduced the payment for a reason that is neither contractual nor patient responsibility. Often appealable.
Frequently asked questions
What's the difference between PR and CO?
PR (Patient Responsibility) is what you owe. CO (Contractual Obligation) is what the provider writes off because they're in-network. Your EOB's 'You owe' column is the sum of PR adjustments.
Can I appeal a PR adjustment?
PR amounts that reflect your normal cost-sharing (deductible, copay, coinsurance) generally aren't appealable — that's just how your benefits work. But PR adjustments for excluded services (like PR-204 'not covered under benefit plan') can be appealed if the exclusion violates federal law (essential health benefits, mental health parity, preventive coverage).
What if my OOP maximum was already met?
If you've hit your out-of-pocket maximum for the plan year, the carrier should NOT be applying additional coinsurance or copay to PR. Request a corrected EOB and reference your accumulator. ACA §1302 caps OOP max at the federal level.
Common CARC codes under group PR
- CARC 1 — Deductible Amount
- CARC 2 — Coinsurance Amount
- CARC 3 — Co-payment Amount
- CARC 96 — Non-covered charge(s).Typically appealable
- CARC 142 — Monthly Medicaid patient liability amount.
- CARC 178 — Patient has not met the required spend down requirements.
- CARC 201 — Patient is responsible for amount of this claim/service thro…
- CARC 204 — This service/equipment/drug is not covered under the patient…Typically appealable
- CARC 238 — Claim spans eligible and ineligible periods of coverage, thi…Typically appealable
- CARC 241 — Low Income Subsidy (LIS) Co-payment Amount.
Sources
Contact: hello@denialhelp.com