PR-45 denial code
The charge exceeds the fee schedule or allowed amount — and unlike CO-45, the PR prefix marks the excess as the patient's. That grouping is only legitimate in specific situations, so this code deserves a suspicious read before anyone gets billed.
PR — Patient Responsibility. The amount is the patient's to pay: deductible, coinsurance, or copay. These are not denials, and they are collectible.
Why you got it
- 1A genuinely out-of-network claim where the plan pays its OON allowance and leaves the balance to the patient.
- 2A payer grouping error: an in-network claim's contractual write-off mislabeled PR — it happens, and it invites a balance bill your contract forbids.
- 3A service where the patient accepted charges above the allowance in writing beforehand.
How do I fix a PR-45 denial?
- Establish network status for this plan and date first. If you are in-network, the excess is a write-off no matter what the prefix says — flag the remit error to the payer and do not bill the patient for it.
- If out-of-network, check surprise-billing protections (emergency care, OON providers at in-network facilities) before billing; where they apply, the patient owes in-network cost sharing and the rest is between you and the plan.
- Where balance billing is genuinely permitted and disclosed, bill the balance — with an explanation, because this bill is the kind patients call about.
How to stop the next one
Post by rule, not by prefix. A posting process that blindly bills whatever lands in PR will eventually balance-bill someone your contract or federal law says you can't — and that mistake costs more than the balance.
Our diagnosis scrubber will not catch this one. PR-45 is driven by procedure codes, modifiers, or eligibility rather than by the diagnosis set — and procedure-side checking needs CPT codes, which aren’t included yet. We would rather tell you that than sell you a tool that quietly misses your most common denial.
If denials like this are a volume problem rather than a one-off, the denial management page explains how the paid workspace catches the coding causes on every claim, and the free ICD-10-CM lookup shows the coding notes behind any diagnosis code on the remittance.