PR-3 denial code: co-payment amount

Claim adjustment reason code 3 is the co-payment amount: a fixed dollar amount the patient's plan sets for a type of service, such as a specialist visit.

With group code PR, it is the patient's responsibility. The payer has paid the rest of the allowed amount, less the copay.

• Copay (PR-3): a fixed amount per visit or service.
• Coinsurance (PR-2): a percentage of the allowed amount.
• Deductible (PR-1): the amount the patient pays each year before the plan starts paying.

A single claim can carry more than one of them.

A copay is known before the visit, so it should be collected at check-in. It turns into a balance when:

• The front desk didn't know the amount, because the plan or the service type wasn't checked.
• The copay differs by service, for example a specialist or therapy copay rather than a primary care one.
• The patient's plan changed and the record shows the old copay.
• Collection at check-in was skipped when the desk was busy.

1. Bill the patient promptly for any copay not collected at the visit, with the payer's explanation.
2. Check for a secondary plan that covers copays.
3. Remember QMB patients: federal law bars billing patients in the Qualified Medicare Beneficiary program for Medicare cost-sharing.
4. Fix the check-in step so the next copay is collected on the day.

• Check the copay for each visit's service type before the patient arrives.
• Collect at check-in, every visit.
• Re-check the plan when the patient's coverage changes.

PR-3 is known before the visit, so it is estimated at booking and collected at check-in.

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 is left uncollected at your front desk.