RemitBench/Denial codes/PR-2

PR-2 denial code

Code 2 is coinsurance: the patient's share of a covered service, worked out as a percentage. Nothing was denied. The only thing worth checking is which number the percentage was taken from.

The code list's own wording: Coinsurance Amount

What actually varies here

The percentage itself is rarely wrong. These are the things that make a correct percentage produce an unexpected number.

• The allowed amount was lower than you expected, so the percentage is of a smaller base.
• The service fell in a different benefit category than you assumed. Plans pay different percentages by category, and dental plans do this the hardest.
• The patient is out of network, where the coinsurance percentage is usually worse and the allowed amount is usually lower at the same time.
• The deductible was applied first on the same claim, so the patient sees two charges and reads them as double billing.
• The plan applied an alternate benefit, paying a percentage of a cheaper treatment than the one performed. See CO-234 for the bundling cousin of this.

The letters on a coinsurance line

Coinsurance is patient money by definition, so the letters barely vary.

What to do next

1. Find the allowed amount and check the arithmetic

   Take the allowed amount, subtract any deductible on the same line, then apply the plan's percentage. If your answer and the payer's do not match, you have found something real.

   If they do not match: the usual cause is that the deductible was applied in a different order, or the payer priced the line against a schedule you were not expecting. Both are reprocessing calls.

2. Check for a secondary plan before you bill

   Coinsurance is the single most common thing a secondary plan pays. Billing the patient first creates a refund later.

   If there is a secondary: send it on with the primary remittance attached.

3. Post it against the right category

   If your system tracks patient responsibility by type, keep coinsurance separate from the deductible and the copay. A ledger that lumps them cannot answer the patient's question six months later.

Coinsurance against the codes that look like it

Coinsurance in dental

Dental plans are built on coinsurance tiers, and the tiers are the reason patients think their plan lied to them. The familiar shape is 100% for preventive, 80% for basic and 50% for major, and which tier a procedure sits in is decided by the plan, not by the dentist.

The tier is where the argument is

A patient told a crown is covered at 50% is not surprised by the percentage. They are surprised when a procedure they thought was basic gets paid as major. That is a benefit category question, and the answer is in the plan document, which is exactly what remark N130 tells you to go and read.

Percentages are of the plan's allowed amount, and out of network breaks this

In network, 50% of the allowed amount is predictable. Out of network, the plan sets its own allowed amount, applies the percentage to that, and the patient owes the rest of your fee on top. The plan still says "50% covered", and the patient still pays far more than half.

Questions people ask about PR-2

Is coinsurance taken from my fee or the allowed amount?

The allowed amount, always. A plan that pays 80% of a $140 allowed amount leaves the patient $28. If your fee was $200, the extra $60 is a contractual write-off on a participating contract, not extra patient responsibility.

What is the difference between coinsurance and a copay?

Coinsurance is a percentage of the allowed amount and is only known after the claim is priced. A copay is a flat amount per visit and is known in advance, which is why copays are collected at the desk and coinsurance usually is not.

The patient has a deductible and coinsurance on the same claim. Is that right?

Yes, and it is normal. The deductible comes out first, then the plan's percentage applies to what is left of the allowed amount. Patients often read the two lines as being billed twice, so it is worth explaining as one calculation rather than two charges.

Related codes

• PR-1 The deductible, which is taken out before the coinsurance percentage applies.
• PR-3 The copay. Flat, known up front, and collected at the desk.
• CO-45 The write-off on the same line. Yours, not the patient's.
• CO-234 Not paid separately. When the plan pays for something other than what you billed.
• N130 Read the plan document. The remark that answers most benefit tier questions.

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