What is the difference between PR-1 (deductible) and PR-2 (coinsurance)?

PR-1 is the deductible — a fixed annual dollar amount the patient must pay before insurance starts sharing costs. PR-2 is coinsurance — the patient's ongoing percentage share of each claim's allowed amount after the deductible is met. Once the deductible is met, PR-1 stops appearing and PR-2 continues until the patient reaches their out-of-pocket maximum. At the out-of-pocket maximum, both PR-1 and PR-2 stop and the plan pays 100%.

How is coinsurance calculated?

Coinsurance is calculated as the patient's percentage share multiplied by the insurance-allowed amount for the service. Example: allowed amount $500, patient coinsurance 20% = $100 PR-2. The coinsurance percentage is set in the patient's plan and applies to the payer's allowed amount — not to your billed charge. The insurance pays the other 80% (the plan's share), minus any amounts applied to the deductible.

What is the difference between PR-2 (coinsurance) and PR-3 (copay)?

PR-2 (coinsurance) is a variable percentage of each service's allowed amount — it changes with every claim depending on the allowed amount. PR-3 (copay) is a fixed dollar amount per visit defined in the plan (e.g., $30 per office visit), regardless of the actual cost of the services provided. Some plans use copays for office visits and coinsurance for procedures; others use one or the other. Always check the eligibility response for the specific visit type.

Does PR-2 stop when the patient reaches their out-of-pocket maximum?

Yes — once the patient meets their annual out-of-pocket maximum (which includes PR-1 deductible, PR-2 coinsurance, and PR-3 copays), the plan pays 100% for covered services for the rest of the plan year. PR-2 will no longer appear on EOBs for that patient until the plan year resets. The eligibility response typically shows the out-of-pocket maximum and how much the patient has accumulated — this is useful for predicting when PR-2 collection opportunities end.

What if the patient has a secondary insurance that covers coinsurance?

Many secondary plans — including Medigap plans for Medicare patients and secondary employer plans — specifically cover the coinsurance (PR-2) from the primary payer. If the patient has secondary insurance, bill the secondary with the primary EOB attached before sending any PR-2 patient statement. For Medicare patients with Medigap, the Medigap plan typically pays the 20% Medicare coinsurance, leaving $0 patient balance. Always bill secondary before billing the patient for coinsurance.

Can I collect estimated coinsurance before the visit?

Yes — you can collect an estimate of the coinsurance at the time of service based on the eligibility-verified coinsurance percentage and the expected allowed amount. Label it clearly as an estimate and provide a receipt. When the EOB arrives, reconcile the actual PR-2 amount against what you collected: refund overpayments, bill for underpayments. Pre-visit coinsurance collection significantly improves overall patient AR because it captures payment while the patient is engaged with the visit.

What is Medicare's coinsurance rate?

Medicare Part B pays 80% of the Medicare-approved amount after the annual Part B deductible is met. The patient's coinsurance is 20% of the approved amount — this appears as PR-2 on Medicare EOBs. For Medicare inpatient (Part A), coinsurance applies differently by hospital stay duration. Most Medigap (Medicare Supplement) plans cover the 20% Part B coinsurance, so Medicare patients with Medigap typically have $0 patient balance after both Medicare and Medigap pay.

PRPatient Responsibility · CARC Code 2

PR-2

Coinsurance Amount — Patient Is Responsible

Q: What does PR-2 mean on an EOB?

PR-2 means the patient's coinsurance applies to this service — this is the patient's percentage share of the insurance-allowed amount. It is a PR (Patient Responsibility) code, so the provider can bill the patient for the exact dollar amount shown. Coinsurance applies after the deductible has been met and represents the patient's ongoing percentage share (typically 10–30%) for each covered service.

PR-2 is the patient's coinsurance — their percentage share of the insurance-allowed amount after the deductible has been met. PR-2 is always a percentage of the allowed amount (not your billed charge). Bill the exact PR-2 dollar amount from the EOB. Check for secondary insurance before billing the patient.

Updated August 2026·Group: PR (patient responsibility)·Action: bill patient exact EOB amount; check for secondary first

PR-2 in plain English

PR-2 means the patient owes a percentage of the insurance-allowed amount for this service — their coinsurance share. After the patient meets their annual deductible, they pay a percentage (often 10–30%) of each covered service's allowed amount. The payer pays the rest. Bill the patient the exact PR-2 dollar amount on the EOB. Before billing, verify whether a secondary plan covers the coinsurance.

How Coinsurance Works

The math behind PR-2 and how it appears on the EOB

Coinsurance is always a percentage of the payer's allowed amount — not the billed charge. The EOB shows the math:

Billed Charge
$350.00

Allowed Amount
$200.00

CO-45 Write-off
$150.00

PR-2 Coinsurance (20%)
$40.00

Insurance Payment (80%)
$160.00

Patient Bill (PR-2)
$40.00

The patient is billed $40 (the PR-2 amount) — not the $150 difference between billed charge and insurance payment. Billing $190 instead of $40 would be a balance billing violation.

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Always check for secondary insurance before sending a PR-2 statement

Medigap plans, secondary employer plans, and Medicaid all commonly cover the coinsurance (PR-2). Billing the patient for a coinsurance that their secondary will pay creates unnecessary collection friction and may constitute a billing compliance issue. Verify secondary coverage at eligibility before every visit.

Step-by-Step Collection

How to handle PR-2 — from eligibility to patient statement

Verify coinsurance percentage and secondary coverage at eligibility
The eligibility response shows the patient's coinsurance percentage by service category and any secondary insurance on file. Check whether the deductible has been met (if not, PR-1 applies before PR-2). Check whether a secondary payer covers the coinsurance — for Medicare patients especially, Medigap plans commonly pay the 20% Part B coinsurance, leaving $0 patient balance.
Estimate coinsurance and collect at the time of service (if no secondary)
If the patient has no secondary that covers coinsurance: estimate PR-2 as the coinsurance percentage multiplied by the expected allowed amount. Collect this estimate at check-in. Label it as an estimate pending the final EOB. Note that coinsurance only applies after the deductible — verify the deductible status in the eligibility response first.
Receive the EOB and identify the exact PR-2 amount
The EOB line for this service shows the allowed amount, the CO-45 contractual write-off, the insurance payment, and the PR-2 coinsurance the patient owes. The PR-2 dollar amount is the only amount you may bill the patient — not your billed charge, not the CO-45 difference, not any other figure.
Submit to secondary before billing the patient
If a secondary payer is on file, submit the secondary claim with the primary EOB attached. Do this before sending any patient statement. The secondary may pay some or all of the PR-2 amount, reducing or eliminating the patient balance. Sending a patient statement for a PR-2 that the secondary will pay creates a refund scenario and erodes patient trust.
Send patient statement for any remaining PR-2 balance
After secondary adjudication (or immediately if no secondary), send the patient statement showing the confirmed PR-2 patient balance. Include the date of service, what insurance paid, and the amount owed. Send within 14 days of EOB posting for best collection rates.

Frequently Asked Questions: PR-2

PR-2 means the patient's coinsurance applies — their percentage share of the insurance-allowed amount. It's a patient responsibility code (PR group), so the provider can bill the patient for the exact dollar amount shown on the EOB.

PR-1 is the deductible (a fixed annual dollar amount the patient pays before insurance starts). PR-2 is coinsurance (the patient's ongoing percentage share of each claim's allowed amount after the deductible is met). PR-1 applies first; once the deductible is met, PR-2 applies until the out-of-pocket maximum is reached.

PR-2 = (Patient's coinsurance percentage) × (Payer's allowed amount). Example: 20% × $200 allowed = $40 PR-2. It is always based on the allowed amount, never the billed charge. The payer performs this calculation and shows the result on the EOB — you don't need to calculate it yourself, but understanding the math helps you verify the EOB is correct.

Yes — once the patient's annual out-of-pocket maximum is met (all PR-1 deductible + PR-2 coinsurance + PR-3 copays combined), the plan pays 100% for covered services. PR-2 stops appearing on EOBs for that patient until the plan year resets. The eligibility response shows the out-of-pocket maximum and current accumulation.

Most Medigap plans (Plans G, N, F) cover the Medicare Part B 20% coinsurance. Medicare patients with Medigap typically have $0 patient balance after Medicare (80%) and Medigap (20%) both pay. Always verify the patient's Medigap plan at eligibility before sending a PR-2 patient statement for a Medicare claim. Billing a Medicare patient for coinsurance that Medigap will cover creates unnecessary disputes.

Medicare Part B pays 80% of the Medicare-approved amount after the annual Part B deductible ($257 in 2026). The patient's 20% coinsurance appears as PR-2. For most outpatient services, preventive services are covered at 100% with no coinsurance. Inpatient hospital stays (Part A) have different cost-sharing structures by day of stay.

Related Codes

Codes related to PR-2

PR-2 balances aging? Your patient statement workflow needs tightening.

Coinsurance collected at the visit converts at 80%. The same balance sent on a 60-day statement converts at under 40%. A free RCM audit identifies your patient collection workflow gaps and builds the deductible and coinsurance collection process that starts recovery at the front desk.

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