PR-2: Coinsurance Amount
This portion of the charge is the patient's coinsurance responsibility, the percentage of the allowed amount the patient owes after the deductible is met, per their plan design.
What the group code means
- PR
- Patient Responsibility. The amount may be billed to the patient.
Why it fires
- The plan applies a coinsurance percentage, such as 20 percent, to this service after the deductible
- The service falls under a benefit tier requiring coinsurance rather than a flat copay
Corrective actions, ranked
- 1
Verify the percentage
Confirm the coinsurance percentage applied matches the patient's plan summary.
- 2
Bill the patient for the coinsurance
Route the amount to patient billing as a standard cost share.
- 3
Check secondary coverage
If the patient has secondary insurance, submit the coinsurance amount as a crossover or secondary claim.
Is it worth appealing
Not appealable to the payer. This is a routine cost-share allocation, though secondary insurance may cover it.
Retrieved 2026-07-18.
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DenialPath provides billing and administrative guidance based on published CMS and X12 sources. It is not medical advice, not a coverage determination, and not a guarantee of payment. NCCI and MUE edits are republished quarterly and payer policies vary by contract. Always confirm against the payer's own current policy before submitting or appealing.