The PR-3 denial code means the payer applied a co-payment amount and the patient, not the practice, owes it. PR is the group code for patient responsibility. 3 is the reason code for the copay. It is usually a normal adjustment, not a rejected claim, so post it and bill the patient.
An earlier version of this page described PR-3 as a settled workers’ compensation claim. That is wrong, and it has been corrected here. The code is defined in the standard code lists, and this guide shows where each part comes from. For the wider picture, see our guide to medical billing denials.
Key takeaways
- PR-3 = group code PR (patient responsibility) + reason code 3 (co-payment amount).
- It is a copay adjustment, not a workers’ compensation or Medicare Set-Aside code.
- Bill the patient only for amounts the remittance shows under group code PR.
- Compare PR-3 to the copay collected at the visit before sending a statement.
- A work-related injury denial uses a different reason code, so read the full code pair.
What does the PR-3 denial code mean?
PR-3 means the patient owes a copay on this claim line. The code has two parts. PR is the group code and assigns the unpaid amount to the patient. 3 is the claim adjustment reason code (CARC), and the X12 code list gives its description as Co-payment Amount. The code list shows it in use since 1995 with no stop date.
CMS explains the first half. A Contractual Obligation (CO) group code assigns responsibility to the provider. A Patient Responsibility (PR) group code assigns responsibility to the patient. CMS also says providers may bill Medicare beneficiaries for an unpaid portion only when an adjustment shows group code PR (CMS Medicare Learning Network).
Why it is called a denial code
Many people search for PR-3 as a “denial code” because it appears on the remittance advice next to the amount not paid. In most cases it is an adjustment that moves part of the charge to the patient. The claim itself was processed.
| Part | What it is | What it tells you |
|---|---|---|
| PR | Group code | The patient is responsible for this amount |
| 3 | Claim adjustment reason code (CARC) | The adjustment is a co-payment amount |
| Remark code (RARC), if sent | Supplemental explanation | More detail where the payer adds it |
Source: X12 Claim Adjustment Reason Codes; CMS MLN remittance advice booklet (ICN 905367)
How is PR-3 different from PR-1 and PR-2?
PR-1, PR-2 and PR-3 all assign an amount to the patient, but the reason differs. The X12 list defines CARC 1 as deductible amount, CARC 2 as coinsurance amount and CARC 3 as co-payment amount (Connecticut APCD CARC list and X12 agree).
| Code | Reason code description | What the practice should check |
|---|---|---|
| PR-1 | Deductible amount | Whether the patient’s deductible was already met when you checked benefits |
| PR-2 | Coinsurance amount | The patient’s share of the allowed amount under the plan |
| PR-3 | Co-payment amount | Whether the copay was collected at the visit |
Source: X12 Claim Adjustment Reason Codes (descriptions); the check column is general practice advice
For a fuller look at what a patient can owe and how to explain it, read our guide to patient responsibility in medical billing and the walkthrough on how to calculate patient responsibility.
Is PR-3 a workers' compensation code?
No. CARC 3 is the copay code and has no link to workers’ compensation. The X12 list uses a separate code for that case: CARC 19, described as a work-related injury or illness that is the liability of the workers’ compensation carrier (X12).
The Medicare Set-Aside idea in the old post also does not belong to PR-3. CMS describes a Workers’ Compensation Medicare Set-Aside (WCMSA) as an arrangement that sets aside part of a settlement to pay for future related medical care. The CMS overview does not mention claim adjustment codes (CMS WCMSA overview). If your practice treats work injuries, see our guide to workers’ compensation in the revenue cycle.
| Code | Meaning | Who owes the amount |
|---|---|---|
| PR-3 | Co-payment amount | Patient |
| CARC 19 | Work-related injury or illness; liability of the workers’ compensation carrier | Depends on group code on the remittance |
| CARC 22 | Care may be covered by another payer per coordination of benefits | Depends on group code on the remittance |
| CO-45 | Charge exceeds fee schedule or contracted amount | Provider (write-off) when sent with CO |
Source: X12 Claim Adjustment Reason Codes; CMS MLN remittance advice booklet
What should a practice do when PR-3 appears?
Post the adjustment to the patient’s account, check it against the copay collected, then bill any remaining balance. Do not appeal PR-3 by default, because the claim was usually processed correctly.
- Read the full pair on the remittance advice (the group code, the reason code and any remark code).
- Compare the PR-3 amount with the copay you collected at check-in.
- If you collected the full copay, post it against the PR-3 amount and leave no patient balance.
- If the amount is higher than what you collected, move the difference to patient responsibility and send a clear statement.
- If the amount looks wrong for the patient’s plan, re-run the benefits check before you bill the patient.
A clean posting step helps here. Our guide to the electronic remittance advice (ERA) shows where these codes appear, and our post on insurance verification covers the benefits check that sets the expected copay.
Where do PR-3 problems come from?
Most PR-3 problems are front-end or posting problems, not payer errors. The patient pays the wrong copay, the copay is not recorded, or staff treat PR-3 as a write-off. Each one leaves money unbilled or the patient surprised.
- Copay not collected at the visit, so the amount returns as a patient balance later.
- Copay collected but not posted to the claim, so a balance shows that is already paid.
- Wrong plan or outdated benefits on file, so the copay on the claim does not match the plan.
- PR-3 posted as a contractual write-off. CMS says PR means patient responsibility, so it should not be written off like CO.
“A patient adjustment is only as good as the benefits check and the posting behind it.”
A practice management system that tracks claims by stage with an owner on each claim makes it easier to see which claims still carry an unbilled patient balance. For specialty-specific copay patterns, start at our specialty billing pages.
How does PR-3 compare with CO denial codes?
PR codes move money to the patient. CO codes usually leave the amount with the practice. That one letter changes who you bill, so the group code matters as much as the number.
If you see CO instead of PR, read our guides to CO-45, CO-16 and CO-22. For a case where the practice must act with the payer, our team handles denial management services for practices that want help with appeals and root causes.
Not sure how your remittances are being posted?
Ask for a free practice audit and we will review how patient responsibility codes are posted and billed.
Our recommendations
- Train staff to read both parts of the code. Make sure everyone who posts payments knows that the group code decides who owes the money and the reason code says why.
- Match every PR-3 to the copay collected. Before a statement goes out, compare the PR-3 amount with what was paid at check-in.
- Never write off a PR amount by default. Reserve write-offs for CO amounts that the contract requires, and review any PR write-off with a supervisor.
- Check benefits before the visit. Verify the plan and copay so the front desk collects the right amount the first time.
- Track denial codes by group code and reason code together. Reports that show PR-3 apart from CO-16 or CO-45 make root causes easier to see.
Patient balances are easier to chase when every claim has a stage and an owner.
RCM Finder's practice management portal tracks claims by stage with an assigned owner and offers reporting dashboards, so a PR balance does not sit unbilled.
See how the RCM Finder portal works · Create a portal account
Disclosure: RCM Finder builds and sells this portal. It is a practice management system, not an EHR.
Bottom line
PR-3 is a copay adjustment that the standard code list defines as a co-payment amount, assigned to the patient by group code PR. It is not a workers’ compensation or Medicare Set-Aside code. Read the full code pair, match it to the copay collected, and bill the patient only for what the remittance assigns to them. If your team wants a second set of eyes on posting, our medical billing services cover payment posting and follow-up.
Frequently asked questions
What does PR-3 mean on a remittance advice?
PR-3 means the patient owes a co-payment amount. PR is the group code for patient responsibility and 3 is the claim adjustment reason code for co-payment amount, per the X12 code list.
Is PR-3 a denial?
Usually not. It is an adjustment that assigns part of the charge to the patient, so the claim was processed. Some people call every code on the remittance a denial code, which is why the term is common.
Does PR-3 mean workers' compensation?
No. CARC 3 is the co-payment code. The X12 list uses CARC 19 for a work-related injury or illness that is the liability of the workers’ compensation carrier.
Can I bill the patient for a PR-3 amount?
Yes, for the amount the remittance assigns under group code PR, after you check what was already collected. CMS says providers may bill Medicare beneficiaries for an unpaid portion only when an adjustment shows group code PR. Other payers have their own rules, so check the contract.
What is the difference between PR-3 and CO-45?
PR-3 is a copay assigned to the patient. CO-45 means the charge exceeds the fee schedule or contracted amount, and with group code CO it is usually a provider write-off. See our CO-45 guide for how to handle it.
What if the PR-3 amount is different from the copay we collected?
Recheck the patient’s benefits and plan on file, compare the amounts, and then bill the difference or refund an overpayment as your policy and payer rules require. Do not guess the reason without the remittance and plan details.
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Sources
- Claim Adjustment Reason Codes — X12 (current)
- Medicare Remittance Advice booklet (ICN 905367) — CMS Medicare Learning Network (n/a)
- CARC codes list — Connecticut Office of Health Strategy APCD advisory group (2022)
- Workers' Compensation Medicare Set-Aside Arrangements overview — CMS (n/a)
Disclaimer: This article is educational and is not legal, coding or compliance advice. Code definitions come from the sources listed, and payer rules and contracts vary, so confirm details with the payer.
