What is patient responsibility?
Patient responsibility is the part of a claim the patient owes under their plan: the deductible, coinsurance and copay, reported on the remittance with group code PR.
Patient responsibility on one visit
- Allowed amount
- $400.00
- Deductible remaining
- $150.00
- Coinsurance
- 20% after deductible
| Part | Code | Amount |
|---|---|---|
| Deductible | PR-1 | $150.00 |
| Coinsurance, 20% of $250.00 | PR-2 | $50.00 |
| Plan pays | $200.00 | |
| Patient owes | $200.00 |
- If a secondary plan is on file, this $200.00 goes to the secondary first. Only what it doesn't pay becomes the patient's.
Every remittance splits the allowed amount between the plan and the patient. The patient’s share appears with group code PR and a reason code:
- PR-1, deductible: what the patient pays before the plan starts paying.
- PR-2, coinsurance: a percentage of the allowed amount.
- PR-3, copay: a flat amount per visit or service.
Before it becomes a patient bill
A PR balance isn’t automatically the patient’s to pay. Check that no secondary is pending, that the patient isn’t a QMB or Medicaid patient protected from cost sharing, and that the No Surprises Act doesn’t limit what can be billed. CO adjustments are never the patient’s responsibility.
Why estimates matter
Patients pay more of their bills when they know the amount before the service. An eligibility check showing the remaining deductible is enough to give a good estimate.
Run your revenue cycle as workflows.
We are working with a small group of billing and operations teams to shape worklist. Tell us where your work gets stuck, and we'll show you how it would run.