RemitBench/Denial codes/PR-3

PR-3 denial code

Code 3 is the copay: a flat amount per visit, set by the plan and known before the patient arrives. It is the easiest patient balance to collect and the easiest one to collect twice.

The code list's own wording: Co-payment Amount

When a copay appears and should not

The amount is rarely wrong. Whether there should be a copay at all is the part worth checking.

• Preventive care. Many plans do not charge a copay for it, so a copay on a preventive line is worth questioning.
• The visit was coded as a type the plan charges more for, such as a specialist rate applied to a general visit.
• The patient's plan changed and the front desk collected the old amount, leaving a small balance or a small credit.
• The plan uses coinsurance for this service and a copay appeared instead, or both appeared, which is worth a call.

The letters on a copay line

As with the other two patient money codes, the letters barely vary.

What to do next

1. Match it against the payment already on the account

   Before anything else, look for a copay payment on the date of service. Most of the time it is there and the line needs posting, not billing.

   If the amounts differ: the desk collected the wrong amount. A small refund or a small balance, and either way it is worth fixing the number on file.

2. Ask whether this visit should carry a copay

   Preventive visits are the usual exception. If the plan exempts them and one appeared, that is a reprocessing call rather than a patient conversation.

3. Check the plan did not also apply coinsurance

   Some plans use one or the other for a given service. Both appearing is not always wrong, but it is worth confirming against the plan document rather than assuming.

Copay against the other patient money codes

Copays in dental

Traditional dental indemnity plans mostly use coinsurance, so a flat copay is a signal worth reading. It usually means the patient is on a dental HMO or a managed care style plan with a fixed fee schedule, and those plans behave differently from the ones your team is used to.

A copay plan means the patient schedule is the contract

On these plans the patient's cost for each procedure is set in advance by a schedule, and your reimbursement is set the same way. There is much less to work out per claim, and much less room to bill anything extra. Charging above the schedule is normally a contract breach.

Questions people ask about PR-3

Is PR-3 a denial?

No. The service was covered and processed. Code 3 tells you the plan's fixed per-visit charge landed on this line, and in most practices the patient already paid it at the front desk.

Why do we see a copay when the patient already paid one?

Because the remittance reports the copay the plan applied, whether or not you collected it. It is a statement of what the patient owes, not a new charge. Match it against the payment on the account before you bill anything.

Can a plan charge both a copay and coinsurance?

Some do, though most use one or the other for a given service. If both appear and the plan document does not describe that, it is worth a reprocessing call rather than a patient statement.

Related codes

• PR-1 The deductible. A yearly amount rather than a per-visit fee.
• PR-2 Coinsurance. The percentage version of patient responsibility.
• PR-49 Routine or preventive. Where copay exemptions usually live.
• CO-119 Benefit maximum reached, which is the other reason a patient owes the whole thing.

Back to all denial codes