What to Do When Your Claim Is Denied With Code PR-1 (Deductible Not Met)

How to Understand PR-1, Prevent It, and Fix Incorrect Deductible Denials

When your Explanation of Benefits (EOB) shows PR-1, it means the insurer considers the service your responsibility because your deductible has not been met. But:

Many PR-1 denials are incorrect and can be reversed with proper documentation and appeal.

PR-1 is one of the most commonly misunderstood denial codes because it covers multiple scenarios:

• Deductible truly not met

• Insurer miscalculated your deductible

• Provider billed incorrectly

• Claim was processed out of order

• Insurer assigned services incorrectly as “subject to deductible”

• Preventive care was miscategorized

• Network rules applied incorrectly

• HSA/HRA funds not accounted for

This guide walks you through:

• What PR-1 means

• When the denial is valid

• When it is wrong

• How to correct provider or insurer errors

• When you should appeal

• What documents to include

• How to write a strong PR-1 appeal

• When you’re legally entitled to coverage even with the deductible

1. What PR-1 Actually Means

PR-1 = “Patient Responsibility — Deductible Not Met.”

The insurer is saying:

• You owe the charge

• The service is applied to your deductible

• Your deductible has not been satisfied, so the insurer is not paying

But PR-1 does not mean the claim was denied for medical reasons. It is a cost-share calculation denial, not a coverage denial.

2. Why PR-1 Denials Occur

Reason 1: Your Deductible Truly Has Not Been Met

This is the straightforward scenario: The service is covered, but you pay toward your deductible first.

Reason 2: The Insurer Miscalculated Your Deductible

This is extremely common. Examples:

• Claims processed out of order

• Deductible payments not applied yet

• Other claims still being adjudicated

• Deductible reset date misunderstood

• Insurer applied claim to “out-of-network deductible” by mistake

Reason 3: Provider Billed with Wrong Codes

Coding errors cause insurers to classify services incorrectly. Examples:

• Preventive service billed as diagnostic

• Office visit billed incorrectly

• Modifier missing

• Diagnosis does not match preventive care requirements

If preventive care is miscoded, the insurer may apply it to deductible — incorrectly.

Reason 4: Insurer Misapplied Coverage Rules

Often insurers wrongly apply:

• Deductible to preventive services

• Deductible to screenings that must be covered under ACA

• Deductible to services that require “first-dollar coverage”

• Deductible to follow-up preventive care

These can be appealed and overturned.

Reason 5: Out-of-Network vs. In-Network Confusion

If the provider is:

• Not correctly listed as in-network

• Billed under a different NPI

• Billed through a hospital instead of a clinic
  — the insurer may incorrectly apply claims to the out-of-network deductible.

This often triggers PR-1 but is reversible.

Reason 6: Insurer Error or System Delay

Sometimes the insurer simply:

• Did not update your deductible balance

• Did not process other claims first

• Applied your HSA/HRA incorrectly

• Lost system updates

These errors are common and appealable.

3. Step One: Read the Denial Letter (Not Just the EOB)

Your EOB lists PR-1.
Your denial letter explains why PR-1 was applied.

Look for clues:

• “Deductible not met in current plan year”

• “Service applied to out-of-network deductible”

• “Preventive service billed as diagnostic”

• “Claim processed before prior claims”

• “Provider not participating”

• “Service does not meet preventive criteria”

This determines your next steps.

4. Determine Whether You Need a Corrected Claim or a Patient Appeal

✔ Request a Corrected Claim if:

• Provider billed wrong CPT code

• Preventive service miscoded

• Diagnosis mismatched

• Wrong NPI used

• Provider billed “facility” instead of “office” setting

• Modifier missing

• Service should NOT have been applied to deductible

These must be fixed by the provider, not the patient.

✔ File a Patient Appeal if:

• Deductible was calculated incorrectly

• Claim applied to wrong deductible tier

• Preventive care should have been covered at 100%

• Insurer misinterpreted plan benefits

• Insurer used outdated coverage rules

• Insurer failed to credit prior payments

• Insurer misapplied your plan’s network rules

This is when YOU must appeal.

5. How to Appeal a PR-1 Denial (Step-by-Step)

Here is the structure you (or the customer buying your template) should follow.

1. Identify the Claim Clearly

Include:

• Name

• Member ID

• Claim number

• Date of service

• Provider name

• Denial code: PR-1

2. Explain Why PR-1 Was Incorrect

Sample opening:

“I am appealing the PR-1 determination because the deductible was applied incorrectly. This service should not have been subject to the deductible under my plan’s coverage rules.”

3. Attach Proof of Deductible Payments

Include:

• Receipts

• EOBs showing applied payments

• Provider invoices

• HSA/HRA statements

4. Cite Your Plan Document

Quote the Evidence of Coverage (EOC) to show:

• Services that bypass the deductible

• Preventive care covered at no cost

• Network coverage rules

• Deductible umbrella details

5. Provide a Timeline

Explain:

• What claims were already processed

• What the insurer failed to apply

• Any billing issues

6. Ask for Correct Processing

Example:

“Please recalculate my deductible based on the enclosed evidence and reprocess this claim accordingly.”

6. Appeal Deadlines

Same as other denial types:

ERISA Plans

• 60-180 days to appeal

• Insurer must respond within 30–60 days

Individual / Marketplace Plans

• 60–120 days

• External review available

Medicare / Medicaid

Separate, strict appeal rules.

7. When to Request an External Review

If the insurer:

• Misapplied preventive care rules

• Refuses to credit deductible payments

• Applied deductible to wrong category

• Applied out-of-network deductible incorrectly

You can demand an Independent Review Organization (IRO) review.
IRO decisions are binding in many states.

8. PR-1 Denials Are Often Reversible

Most PR-1 denials are not true denials — they are processing errors or billing mistakes.

You can usually fix them by:

• Requesting a corrected claim,

• Providing deductible payment proof, or

• Filing a concise appeal explaining the error.

Do not assume you owe the bill.
Insurers frequently miscalculate deductible balances.

Was Your Claim Denied With PR-1? Use the Attorney-Drafted Appeal Letter for Deductible Errors.

A PR-1 denial can feel frustrating — especially when you know you paid your deductible or the service should not have been applied toward it.

My PR-1 Deductible Appeal Letter Template includes:

✔ Attorney-written appeal
✔ Arguments for every possible PR-1 scenario
✔ Deductible evidence checklist
✔ Instructions for provider billing fixes
✔ Instant download — use today

👉 Get the PR-1 Appeal Template

You CAN Win Your Appeal

A denial letter is not the final decision. Insurance companies overturn claims every day when people submit a strong appeal.

Whether you use:

➡ The Free Appeal Guide
or
➡ The $29 Professional Appeal Template

—you can absolutely take back control and fight your denied claim with confidence.

Download Your Free Appeal Guide

Get the step-by-step instructions, evidence checklist, and sample wording you need.
Download Free Guide

Need a Full Appeal Letter Template? ($29)

Get a professionally drafted, fill-in-the-blank appeal letter tailored for medical claim denials.
Get the Full Template