PR-1 denial code: deductible amount

Claim adjustment reason code 1 is the deductible amount. The payer processed the claim and applied some or all of the allowed amount to the patient's deductible, the amount the patient pays each year before the plan starts paying.

With group code PR, it is the patient's responsibility. The claim isn't wrong and there is nothing to appeal; the question is who pays it and how it gets collected.

• Is there a secondary plan? A supplemental plan, Medicaid or a second employer plan may pay the deductible. Bill it first, with the primary payer's payment information.
• Is the patient a Qualified Medicare Beneficiary? Federal law bars billing patients in the QMB program for Medicare deductibles, coinsurance and copays.
• Does the amount match? The deductible applied should match the plan's remaining deductible on the date of service.

• Patients don't expect the bill. Early in the year, most visits fall under the deductible.
• Nobody estimated it at the visit, so it is billed weeks later, when patients are least likely to pay.
• High-deductible plans put more of every visit on the patient.

1. Check for a secondary payer and bill it first.
2. Send the patient a clear statement that shows the payer's explanation.
3. Offer an easy way to pay, such as a payment link, and follow up on a schedule.
4. Next time, estimate it before the visit and collect at check-in.

• Estimate the patient's share at booking from their plan's benefits and remaining deductible.
• Tell the patient before the visit, and collect at check-in where your policy allows.
• Track deductible resets at the start of each plan year.

PR-1 is estimated before the visit and collected after the payer answers.

Claira Health's AI agents follow every denial and every payment until it's resolved, and flag money that comes up short. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

Book a 20-minute call to see how much of your patient balance could be collected at the visit.