835 Denial Combination
PR-2+N130
Patient Responsibility · Claim + Service Level Adjustment
Patient ResponsibilityWhat This Combination Means
The patient owes a coinsurance amount as defined by their benefit plan. The payer is directing the provider to reference the plan's benefit documents or guidelines to understand any restrictions that apply to this service and determine the coinsurance percentage or structure. This combination indicates the coinsurance calculation follows plan-specific rules that may not be standard.
Financial Responsibility
patient responsibility
The patient is responsible for the coinsurance amount calculated according to their specific plan's benefit structure. The amount reflects restrictions or guidelines documented in the patient's benefit plan.
N/A
Appeal Success
Immediate (patient statement)
Avg. Resolution
Easy
Difficulty
No
Appealable
Step-by-Step Resolution
Steps tailored specifically to this PR-2+N130 combination — not generic advice.
- 1
Access the patient's benefit plan documents or guidelines
Verify the coinsurance percentage and any service-specific restrictions that apply to this claim per RARC N130 instruction
- 2
Validate coinsurance calculation against plan guidelines
Ensure the coinsurance amount transferred to patient responsibility aligns with the benefit plan's documented structure and restrictions
- 3
Transfer coinsurance amount to patient account and generate statement
Bill the patient for the coinsurance amount as contractually required under their benefit plan
Specialty Context
How PR-2+N130 typically presents across different practice types.
Dental
Coinsurance percentages vary widely by dental plan tier (preventive, basic, major); consult plan documents to verify category-specific coinsurance rates before billing patient
Medical
Coinsurance typically applies after deductible is met; service restrictions may include tier-based coinsurance rates for in-network vs out-of-network providers or specialty services
Behavioral Health
Mental health parity laws require coinsurance rates comparable to medical benefits; verify plan documents do not impose higher coinsurance for behavioral health services than medical/surgical services
Individual Code References
View the standalone definition for each code in this combination.
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