PR-1: Deductible Amount

Why it fires

• The patient has not met their annual deductible yet
• The visit or service is subject to deductible per the plan design rather than covered at 100 percent
• The deductible resets at the start of a new plan or calendar year and this is an early-year claim

Corrective actions, ranked

1. 1

   Confirm deductible status

   Verify the patient's remaining deductible via the payer portal or EOB to make sure the amount applied is accurate.

2. 2

   Bill the patient

   This amount is standard patient responsibility. Transfer the balance per your normal patient billing workflow.

3. 3

   Check for deductible waivers

   Some preventive or plan-specific services are deductible-exempt. Confirm this service was correctly categorized.

Is it worth appealing

Not an appealable denial. This is a normal cost-share application, though you can dispute it if the service should have been exempt from the deductible under the plan or preventive care rules.

Other denial codes to check

Codes that share a remark code with this one, or that are reported under the same group code.

• PR-204This service/equipment/drug is not covered under the patient's current benefit plan
• PR-50These are non-covered services because this is not deemed a 'medical necessity' by the payer.
• PR-151Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
• PR-96Non-covered charge(s).
• PR-2Coinsurance Amount
• PR-3Co-payment Amount

See every CARC in the dataset