PRPatient Responsibility · CARC Code 1
PR-1

Deductible Amount — Patient Is Responsible

PR-1 is the deductible adjustment on the patient's EOB. The payer is telling you this portion of the claim applies to the patient's annual deductible — the patient owes it, you can bill them for it. PR-1 appears on virtually every claim until the deductible is fully met.

Updated August 2026·Group: PR (patient responsibility)·Action: bill the patient the exact EOB amount
Most commonPR-1 Appears on More Claims Than Any Other Code
Jan 1 resetCalendar-Year Deductibles Reset Every January
Bill patientPR Group Code = Patient Can Be Billed
Exact EOB $Never Bill More Than the PR-1 EOB Amount
PR-1 in plain English

PR-1 means the patient's annual deductible applies — this portion of the claim is the patient's financial responsibility. The payer has adjudicated the claim and determined that the patient has not yet met their deductible for the plan year. You can bill the patient the exact dollar amount shown as PR-1 on the EOB. Never bill the patient more than the PR-1 amount — that's a balance billing violation under nearly every payer contract.

Deductible Structures

Individual, family, embedded, and non-embedded — what the eligibility response is telling you

Individual Deductible

The amount each covered member must pay out-of-pocket before the plan starts covering their claims. Each person on the plan has their own individual deductible. PR-1 applies until this individual limit is met. Common amounts: $500–$3,000 for commercial PPO, $1,600 for Medicare Part B in 2026.

Family Deductible

The aggregate amount all family members together must pay before the plan pays at the benefit level for all family members. In a non-embedded structure, no single member's claims are covered until the family aggregate is met. In an embedded structure, individual limits apply first.

Embedded Deductible

Each family member has their own individual deductible cap within the family deductible. Once one member meets their individual limit, the plan starts paying for that member — even if the family aggregate isn't met. Most commercial PPO plans use embedded structures. Verify at eligibility.

Non-Embedded (Aggregate) Deductible

No individual member gets full coverage until the family aggregate deductible is met in total. Common on HDHP/HSA plans and some Marketplace plans. One family member cannot "unlock" coverage for themselves independently — the whole family deductible pool must be filled first.

In-Network vs. Out-of-Network Deductible

Most PPO plans have separate deductibles for in-network and out-of-network services. PR-1 on a claim from a participating provider draws down the in-network deductible. If the provider is out-of-network, a higher separate deductible applies. The eligibility response shows both balances.

Medicare Part B Deductible

Medicare Part B has an annual deductible ($257 in 2026) that applies before Medicare pays 80% of the allowed amount. PR-1 on Medicare claims means the Part B deductible hasn't been met. After the deductible, the patient pays the 20% coinsurance (PR-2). Most Medigap plans cover the Part B deductible.

Collection Timing

Deductible collection rates drop sharply after the visit

The best time to collect deductible balances is at the point of service — before the patient leaves. Every week that passes after the visit reduces the probability of collection.

~80%
Collection rate when deductible is collected at the visit (time of service)
~60%
Collection rate on first patient statement sent within 14 days of EOB
~45%
Collection rate on statement at 30–60 days after service
<30%
Collection rate on balances over 90 days — before any collection costs
💡
Collect at check-in, not check-out

Patients collected at check-in pay. Patients asked at check-out often defer. Eligibility the day before, estimate at check-in, collect before the visit — this one process change recovers more deductible revenue than any statement follow-up program.

Collection Workflow

How to collect deductible (PR-1) without billing problems

  1. Verify deductible balance at eligibility check before the appointment
    Pull the 271 eligibility response or check the payer portal the day before (or morning of) the visit. Record the individual deductible, family deductible, and remaining balance for each. Note whether the plan is embedded or non-embedded and whether in-network and out-of-network deductibles differ. This is your collection estimate source.
  2. Estimate the deductible portion of today's visit and collect it at check-in
    Using the expected allowed amount for the planned services and the remaining deductible balance, calculate the lower of the two as the estimated patient liability. Collect this estimate at check-in with a signed acknowledgment that it is an estimate subject to the final EOB. Provide a receipt. Do not wait until checkout — collection rates fall immediately once the visit is over.
  3. Receive the EOB and compare the actual PR-1 to your estimate
    When the ERA or EOB posts, look at the PR-1 line for the exact adjudicated deductible amount. If you collected more than the PR-1 amount, refund the difference within 30 days. If you collected less, send a patient statement for the remaining amount. The PR-1 EOB amount is the legally correct amount to bill — not your billed charge, not your estimate.
  4. Send any remaining patient statement within 14 days of EOB posting
    If the patient still has a PR-1 balance after what was collected at the visit, batch the patient statement within 7–14 days of the EOB posting. Show the date of service, the insurance payment amount, and the exact PR-1 patient balance due. Include a payment due date (30 days), payment portal or phone number, and a brief explanation. Patients forget visits quickly — prompt statements while the visit is fresh improve collection rates substantially.
  5. Track and alert for deductible resets in January
    January is the highest-risk month for deductible undercollection. Every patient who had a fully-met deductible in December returns in January with a completely fresh deductible. During the first 6 weeks of each calendar year, re-verify deductible status at every visit regardless of prior history. Flag non-calendar-year plan anniversaries in your PM system so the same alert fires before those resets too.
Prevention & Best Practices

Turning PR-1 from AR problem into upfront collection

  • Run eligibility 24–48 hours before every appointment, not at check-in. Same-day eligibility misses deductible balance updates from the prior day's EOB processing. Day-before verification gives you time to prepare the collection conversation and have it ready at check-in rather than fumbling through a portal while the patient stands at the desk.
  • Store the deductible balance in your PM system and attach it to the appointment. Front-desk staff shouldn't have to re-verify every visit. When the scheduler creates an appointment, eligibility with deductible data should auto-populate into the patient account. The desk sees the balance; they know what to collect.
  • Use a written Good Faith Estimate for high-deductible patients scheduled for procedures. For uninsured patients (required under the No Surprises Act) and as best practice for high-deductible insured patients, provide a written estimate before service showing the expected deductible portion. This sets expectations and reduces payment friction at collection time.
  • Set a January 1 deductible reset alert across your scheduling system. Add a rule that flags all returning patients in January and early February for deductible re-verification. Don't rely on staff memory — automate the flag. This single change eliminates most January deductible collection failures.
  • Report PR-1 collection rates separately from insurance AR. PR-1 balances that remain in your AR after 60 days are patient collection failures, not payer issues. Report deductible AR aging by age and source separately from insurance-pending AR so you can see the collection conversion rate and act on it before balances age out.

Frequently Asked Questions: PR-1

PR-1 means the patient's annual deductible applies to this service and the patient is responsible for the dollar amount shown. The PR group code confirms this is patient responsibility — the provider can and should bill the patient. Always bill the exact EOB amount, never more.
Yes — PR-1 authorizes the provider to bill the patient for this exact amount. The payer has determined this portion is the patient's contractual obligation under their plan. Bill the exact PR-1 dollar amount from the EOB. Billing the patient for more than the PR-1 amount (or the billed charge, whichever is lower) is a balance billing violation under most payer contracts.
Most commercial plans have calendar-year deductibles that reset on January 1. A patient who fully met their deductible in November or December starts the new year with a fresh full deductible. Always re-verify deductible balances at the first visit of each calendar year rather than assuming the prior year's met deductible carries over.
PR-1 is the deductible — the fixed annual amount the patient must pay before insurance begins sharing costs. PR-2 is coinsurance — the patient's percentage share (e.g., 20%) of the allowed amount after the deductible has been met. PR-1 appears on claims before the deductible is met; PR-2 appears on claims after. Both authorize billing the patient.
No — CARC 1 (the number) is a deductible adjustment in both cases, but CO-1 would mean the provider absorbs the adjustment (rare, usually for capitated plans). PR-1 means the patient is responsible. In practice, deductibles on commercial and Medicare Advantage plans are almost always coded as PR-1. If you see CO-1 on a standard PPO claim, it may be a payer error — call to verify.
Medicare Part B has an annual deductible ($257 in 2026) that must be met before Medicare pays 80% of the allowed amount. This deductible appears as PR-1 on the Medicare EOB. Most Medigap plans (Medicare Supplement plans) cover this deductible, in which case the Medigap payer — not the patient — pays the PR-1 amount. Always verify whether the patient has Medigap coverage before billing them for a Medicare Part B PR-1.
Related Codes

Codes related to PR-1

PR-2
Coinsurance — patient's percentage share after deductible is met
PR-3
Copayment — fixed patient payment amount per visit
CO-29
Timely filing — watch the clock while deductible disputes are worked
All codes →
Full CARC & RARC denial code reference

PR-1 balances aging past 60 days? Your deductible collection workflow has a gap.

Deductible balances collected at the visit have an 80% collection rate. The same balances sent as a 60-day statement have less than 40%. A free RCM audit identifies exactly where your patient collection workflow is breaking down and builds the deductible collection process that closes the gap at the front desk.

Get a Free RCM Audit → Patient Collections Guide