PR-241: Low Income Subsidy Co-payment Adjustment

What Does PR-241 Mean?

PR-241 shows the LIS co-payment amount the patient is responsible for paying. This is the reduced co-payment based on their subsidy level. For full LIS beneficiaries, this amount is very low or zero. The provider should collect this specific amount and no more.

CARC 241 communicates the Low Income Subsidy (LIS) co-payment adjustment for Medicare Part D beneficiaries who qualify for financial assistance. The LIS program (also called Extra Help) reduces the co-payment amounts for Medicare beneficiaries with limited income and resources. This code is not a denial — it is an adjustment that shows the reduced co-payment amount the patient is responsible for based on their LIS eligibility level.

There are different LIS levels with corresponding co-payment amounts. Full LIS beneficiaries (those receiving full Medicaid benefits or SSI) pay very low co-payments (often $0 to a few dollars per prescription). Partial LIS beneficiaries have higher but still reduced co-payments. The co-payment schedule is updated annually by CMS.

This code can appear with PR (the adjusted co-payment is the patient's responsibility to pay) or CO (the co-payment reduction is absorbed by the provider or plan as a contractual adjustment). The most important action is verifying the patient's current LIS eligibility level to ensure the correct co-payment is being applied.

Common Causes

How to Resolve

Verify the patient's LIS eligibility level, confirm the co-payment amount matches their eligibility category, and collect the correct amount or request reprocessing if wrong.

1. Verify LIS level Confirm the patient's LIS eligibility category at the time of service. Co-payment amounts vary by LIS level and drug type.
2. Collect the correct amount Collect only the LIS-approved co-payment from the patient. Charging more than the approved amount to an LIS-eligible beneficiary violates program rules.
3. Update records if needed If the LIS level was incorrect, update the patient's eligibility information and request reprocessing to correct the co-payment amount.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-241:

How to Prevent PR-241

• Verify LIS eligibility at every encounter using electronic eligibility tools
• Train staff on LIS co-payment schedules and how eligibility levels affect the amounts
• Stay current with CMS annual updates to LIS co-payment amounts
• Collect LIS co-payments at the point of service to prevent collection issues later

General Prevention

• Implement electronic eligibility verification that includes LIS status checks at the point of service
• Verify patient LIS eligibility at every encounter, as status can change quarterly
• Train front desk and billing staff on LIS eligibility categories and the corresponding co-payment amounts
• Stay current with CMS updates to LIS co-payment schedules and eligibility criteria

Also Filed As

The same CARC 241 may appear with different Group Codes:

Related Denial Codes