PR-2 Denial Code: Patient Coinsurance Responsibility

Corrected Claim or Appeal

These are different routes and choosing wrong costs time. If the denial was caused by something fixable on your side, a wrong modifier, a missing authorization number, or a transposed code, submit a corrected claim. It is faster and does not consume an appeal level. File a formal appeal when the original claim was correct and you believe the payer applied its policy incorrectly.

What to Submit

Include the remittance advice showing the denial, the claim as originally submitted, the clinical documentation that supports medical necessity, and a short cover letter that cites the payer's own coverage policy. Take the filing deadline from the remittance advice or determination letter for that specific claim rather than a general rule, since it differs by payer and by appeal level.

Medicare Appeal Levels

Original Medicare fee-for-service appeals move through five levels, and each one must be exhausted before the next:

1. 1Redetermination by the Medicare Administrative Contractor (MAC)
2. 2Reconsideration by a Qualified Independent Contractor (QIC)
3. 3Decision by the Office of Medicare Hearings and Appeals (OMHA)
4. 4Review by the Medicare Appeals Council
5. 5Judicial review in federal district court

Source: CMS, Medicare Fee-for-Service Appeals