How to Work PR-1 for TRICARE

PR-1 is a Patient Responsibility (PR) CARC indicating that the deductible amount has been applied to the claim. The patient is responsible for paying this amount before the insurance plan begins covering services. This is not a denial — the claim was processed, but the patient owes the deductible portion.

PR-1 occurs when the patient's insurance plan has a deductible that has not yet been met. The deductible is the amount the patient must pay out-of-pocket before insurance coverage begins. Until the deductible is met, the patient is responsible for the allowed amount (after any network discounts). Deductibles reset annually, typically at the beginning of the plan year.

• 1TRICARE Select annual deductible not yet met
• 2TRICARE Select has per-fiscal-year deductibles (individual and family)
• 3TRICARE Prime typically has no deductible but may have copayments
• 4Deductible reset at the start of the fiscal year (October 1)

• ERA/EOB showing the deductible amount applied (PR-1)
• Patient's insurance card and benefit information
• Patient financial responsibility agreement (signed at registration)
• Evidence of deductible amount and remaining balance

1. 1Review the ERA/EOB to confirm the PR-1 amount and the total allowed amount.
2. 2Verify the patient's deductible amount and remaining balance through the payer portal.
3. 3Confirm the patient was informed of potential financial responsibility before the visit.
4. 4Check if the patient has already made any payments toward the deductible.
5. 5Determine if there are other claims that may have applied to the deductible since this claim was processed.

1. 1Bill the patient for the PR-1 amount with a clear statement showing the EOB details.
2. 2If the patient disputes the charge: provide the EOB and verify the deductible status with the payer.
3. 3If the deductible has been met since the claim was processed: request a reprocessing from the payer.
4. 4Offer payment plans for patients who cannot pay the full amount upfront.
5. 5Follow up on patient statements according to your standard collection process.

PR-1 is generally not appealable because it reflects the patient's plan design. However, if the deductible was already met before the date of service and the payer incorrectly applied the deductible, file a formal appeal with proof of the deductible status (e.g., portal screenshot or payer correspondence showing the deductible was met).

• Verify patient eligibility and benefits before the visit, including deductible status.
• Inform patients of their potential financial responsibility before the visit.
• Have patients sign a financial responsibility agreement at registration.
• Collect estimated patient responsibility at the time of service when possible.
• Post ERA/EOB adjustments promptly to avoid delayed patient billing.
• Train front desk staff to explain deductibles to patients.
• Use patient-friendly statements that clearly show the EOB breakdown.