Patient responsibility

Denial code PR-1: Deductible amount

The service was covered, but the amount fell within the patient’s unmet annual deductible, so the plan paid nothing toward it and the balance moves to the patient.

Reason code

CARC 1

Typical group code

What PR-1 actually means

PR-1 is not a denial at all — it is a correctly adjudicated claim where the allowed amount was applied to the patient’s deductible. The payer has confirmed the service is covered and has priced it at the contracted rate; the patient simply has not yet met the deductible for the plan year, so the responsibility for that portion is theirs. The dollar amount reported alongside PR-1 in the remittance is the exact amount you are entitled to collect from the patient.

Why this denial happens

The patient is early in the plan year and has not met their deductible.
The plan has a separate deductible for a specific benefit category (imaging, DME, specialist visits).
The patient changed plans mid-year and the deductible reset.
Eligibility was verified before the plan year rolled over and the new deductible was never re-checked.

How to resolve a PR-1 denial

Do not appeal. Confirm the allowed amount and the PR-1 dollar figure on the remittance.
Post the payer adjustment, then transfer the PR-1 balance to patient responsibility.
Bill the patient promptly — deductible balances collected within 30 days of the remittance are collected at a materially higher rate than those billed at 90 days.
If a secondary payer exists, send the claim to them with the primary’s remittance before billing the patient.

How to prevent it

Run a real-time eligibility check that returns the remaining deductible, not just active/inactive coverage.
Collect an estimated patient portion at time of service when the deductible is known to be unmet.
Re-verify every patient in January and whenever the plan year rolls over.

Frequently asked

What does denial code PR-1 mean?

The service was covered, but the amount fell within the patient’s unmet annual deductible, so the plan paid nothing toward it and the balance moves to the patient. The X12 description reads: "Deductible amount."

How do I fix a PR-1 denial?

Do not appeal. Confirm the allowed amount and the PR-1 dollar figure on the remittance. Post the payer adjustment, then transfer the PR-1 balance to patient responsibility. Bill the patient promptly — deductible balances collected within 30 days of the remittance are collected at a materially higher rate than those billed at 90 days. If a secondary payer exists, send the claim to them with the primary’s remittance before billing the patient.

Can PR-1 be billed to the patient?

This code normally moves the balance to patient responsibility, subject to your payer agreement and to any advance notice of non-coverage requirements that apply.

Related denial codes

PR-2 · Coinsurance amount PR-3 · Co-payment amount CO-119 · Benefit maximum reached

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General revenue-cycle guidance, not legal, coding, or payer-specific advice. Claim adjustment reason codes are maintained by X12 and are revised periodically; payer policy and your provider agreement govern in any specific case. Always read the remark codes transmitted with the denial — they frequently carry the detail this code does not.