PR-1 denial code
Deductible amount
How to fix it
Bill the patient. Confirm the deductible was applied correctly against their accumulated year-to-date amount.
How to prevent it
Check real-time deductible status at eligibility verification so patients can be given accurate estimates and collected at the point of service.
In practice
A claim adjudicates with PR-1 — the amount applied to the patient's deductible. The plan is active, the service is covered, and nothing was denied. The patient simply has not yet met their annual deductible, so the allowed amount falls to them.
The practice receives no payment from the payer on this claim and bills the patient for the allowed amount.
The predictable difficulty is January, when deductibles reset. A patient accustomed to a small copayment suddenly owes the full allowed amount, and unless the practice checks deductible status and says so at check-in, that arrives as a surprise bill weeks later.
What sits behind it
PR-1 is not a denial and should never be worked as one. It is correct adjudication of a covered service against the patient's benefit design, and the only revenue cycle question is collection.
The volume of it has grown with high-deductible plan design, which has shifted a substantial share of revenue from payers to patients. Patient balances collect at materially lower rates than payer balances, and they get harder to collect the further they sit from the visit.
Deductible status is available in the eligibility response, which makes point-of-service collection possible rather than aspirational. Practices that check the remaining deductible and collect at check-in convert the hardest balance in the revenue cycle into the easiest.
Related codes
Terms used here — Patient Responsibility · Allowed Amount · Eligibility Verification
How we handle it — Patient Collections · Eligibility Verification · Patient Support
Primary sources
The rules behind PR-1, at the bodies that publish them.
- Medicare Claims Processing Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — The operative manual for how Medicare claims must be coded, submitted, adjusted and appealed. When a payer policy and a vendor's advice disagree, this settles it.
- No Surprises Act guidance (opens in a new tab)
Centers for Medicare & Medicaid Services — Balance billing restrictions, good faith estimates and the independent dispute resolution process — all of which change what a practice may bill a patient.
Every denial code with a guide
Authorization
Bundling
Contractual
Coverage
Data quality
Documentation
Eligibility
Liability and workers comp
Patient responsibility
- PR-204Not Covered by the Plan
- PR-1Deductible Amount
- PR-2Coinsurance Amount
- PR-3Copayment Amount
Provider eligibility
Timely filing
Looking for a different code? Search all 190 CARC and RARC codes
Questions about PR-1
No. It is the allowed amount applied to the patient's deductible on a covered service. The plan is working as designed — the patient has not yet met their annual deductible, so the balance falls to them rather than the payer.
Because deductibles reset at the start of the plan year. A patient used to paying a small copayment suddenly owes the full allowed amount, and unless deductible status is checked and explained at check-in, it arrives as a surprise bill weeks later.
At the point of service. Deductible status is available in the eligibility response, so the remaining amount is knowable before the visit ends. Patient balances collect at materially lower rates the further they sit from the encounter.
They identify which part of the patient's cost share applies. PR-1 is the deductible, PR-2 is coinsurance, and PR-3 is the copayment. All three are patient responsibility on covered services rather than denials.
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