PR-2 denial code
Coinsurance amount
How to fix it
Bill the patient, or the secondary payer if one exists.
How to prevent it
Quote coinsurance at the point of service using verified benefits so the balance is not a surprise.
In practice
A claim adjudicates with PR-2 — coinsurance. The patient has met their deductible, so the plan now shares cost at the stated percentage, commonly eighty per cent payer and twenty per cent patient.
The practice receives the payer's share and bills the patient for the coinsurance portion of the allowed amount — not of the billed charge, which is a distinction patients frequently misunderstand.
Explaining that coinsurance applies to the contracted allowed amount rather than the practice's charge resolves most of the disputes this generates, and is easier said at check-in than in a collections call.
What sits behind it
Coinsurance differs from a copayment in a way that matters for collection. A copayment is a fixed amount known before the visit. Coinsurance is a percentage of an allowed amount that is not finally determined until adjudication, so the exact figure cannot be stated with certainty in advance.
It can be estimated closely, though, where contracted rates are loaded. An estimate given at check-in, framed as an estimate, is far better than silence — it sets expectation and enables collection of a deposit against the eventual balance.
Out-of-network coinsurance is the version that produces genuine distress, because the percentage is applied to a larger base and the patient may additionally be responsible for the difference between the allowed amount and the charge. Identifying network status before the service is what prevents that conversation.
Related codes
Terms used here — Patient Responsibility · Allowed Amount · Out-of-Network
How we handle it — Patient Collections · Eligibility Verification · Patient Support
Primary sources
The rules behind PR-2, 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-2
A copayment is a fixed amount known before the visit. Coinsurance is a percentage of the allowed amount, which is not finally determined until adjudication — so the exact figure cannot be stated with certainty in advance, only estimated.
No, on the contracted allowed amount. This is one of the most common patient misunderstandings, and explaining it at check-in resolves most of the disputes it otherwise generates.
Closely, where contracted rates are loaded in the system. An estimate offered as an estimate sets expectation and supports collecting a deposit, which is far better than saying nothing and billing later.
Because the percentage applies to a larger base, and the patient may additionally owe the difference between the allowed amount and the full charge. Identifying network status before the service is what prevents that.
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