Copay (Copayment)
A copay is a fixed dollar amount a patient pays for a covered service — for example $30 for an office visit or $75 for urgent care — regardless of the allowed amount. Unlike coinsurance, it does not vary with the charge, and it is due at the time of service.
- Type
- Fixed dollar amount per service
- Collected
- At check-in, before the visit
- ERA code
- PR-3 (patient responsibility: copayment)
- Counts toward
- Out-of-pocket max; usually NOT the deductible
How does a copay work?
A copay is the flat fee attached to a service category: $30 primary care, $60 specialist, $75 urgent care, $250 ER — whatever the plan design says. It does not scale with the charge. Whether the visit's allowed amount is $92.40 or $250, a $30 office copay is $30. On the remittance it shows as PR-3, and the payer deducts it from the payment: allowed $92.40 minus $30 copay means the plan pays $62.40 and the patient owes exactly $30.
What is the difference between a copay, coinsurance, and deductible?
They are the three shapes patient responsibility takes, and they stack in a defined order. The deductible is the amount the patient pays in full before the plan shares costs. Coinsurance is a percentage split after the deductible. A copay is a flat fee that typically applies regardless of deductible status.
Same visit, three designs: allowed amount $92.40. Copay plan: patient pays $30 flat. Coinsurance plan (deductible met, 20%): patient pays $18.48. High-deductible plan (deductible not met): patient pays the full $92.40. One service, three very different check-in conversations — which is why the front desk needs the eligibility response, not a guess.
Why should copays be collected at check-in?
Because a copay is the one patient amount that is known with certainty before the visit — no adjudication required. Collected at check-in, its yield is essentially 100%. Billed on a statement afterward, it costs postage and staff time to chase, and a meaningful share never arrives. A practice with 100 visits a day and a $30 average copay that lets even 15% walk out uncollected is floating $450 a day — over $100,000 a year — into statement purgatory.
What are the common copay mistakes?
- Collecting the card's copay after the plan changed. Renewals reprint copays every January; the eligibility response is current, the card may not be.
- Charging an office copay for a preventive visit. ACA-mandated preventive services are covered without cost share on non-grandfathered plans; collecting a copay on a wellness visit creates refunds and angry calls.
- Applying the specialist copay logic to telehealth. Many plans set distinct (sometimes zero) telehealth copays — verify, do not assume.
- Routine waiving. "We never charge our Medicare patients the copay" is a compliance problem, not a courtesy — see the FAQ above.
Frequently asked questions
Usually not. In most plan designs, copays bypass the deductible entirely — the patient pays the copay whether or not the deductible is met — and copays do not credit toward meeting it. They almost always count toward the annual out-of-pocket maximum, though. Plan documents control, so verify when it matters.
Routinely waiving copays is dangerous. For federal program patients it can implicate the Anti-Kickback Statute and civil monetary penalty rules; for commercial patients it usually breaches your contract and can be treated as fraud, because waiving cost share misstates your actual charge. Documented, case-by-case financial hardship waivers with a policy behind them are the safe exception.
The eligibility (270/271) response returns copay amounts by service type, and the patient's card usually prints office visit, specialist, and ER copays. Card amounts can be stale after plan renewals, so the eligibility response wins when they disagree. On the ERA, the copay appears as PR-3.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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