PR-2 Denial Code: Coinsurance Amount

The official definition

“Coinsurance Amount”

That is the verbatim definition of CARC 2 from the X12 Claim Adjustment Reason Code set, the standardized codes every insurer uses on EOBs and remittance advices. The letters in front of the number are the group code. PR: Patient Responsibility: the insurer says you owe this amount. Verify it against your plan before paying.

What it means in plain English

This is your coinsurance: the percentage of the allowed amount you pay after your deductible is met. Common rates run 10 to 20 percent in-network and 30 to 50 percent out-of-network. PR-2 itself is normal. The two things that go wrong with it are the wrong percentage being applied, and coinsurance continuing to accrue after you've hit your out-of-pocket maximum.

What to check on your EOB

• The percentage. Divide the coinsurance amount by the allowed amount and compare to your plan's stated rate.
• In-network vs. out-of-network. An in-network provider billed at the out-of-network coinsurance rate is a processing error.
• Your out-of-pocket maximum. Once your total cost sharing for the year reaches it, coinsurance on covered in-network care should be zero.

What to do next

1. If the rate doesn't match your plan, call the insurer with your Summary of Benefits in hand and ask them to reprocess.
2. If you've met your out-of-pocket max and coinsurance is still being applied, request reprocessing of this claim and every claim after the date you hit the max.

Who's responsible

You: verify the rate and your out-of-pocket max. Most denials carry a clear owner. Knowing whether the fix belongs to you, your doctor, or the billing office is half the battle. If it's the provider's error, you should not be paying for it.

Want the fundamentals first? Start with how to read an EOB and the 7 most common billing errors. This page is general information about standardized denial codes, not legal or medical advice.