OA-101: Predetermination: Anticipated Payment

What Does OA-101 Mean?

OA-101 may appear when the predetermination involves coordination of benefits or when the payer is providing an informational estimate that does not assign responsibility to any specific party. This is purely informational — no financial action is required until the actual claim is submitted and adjudicated.

When CARC 101 appears, the payer is responding to a predetermination or pre-estimate request rather than processing a final claim. A predetermination is a prospective review where the payer evaluates the proposed service and provides an anticipated payment amount before the service is delivered. This gives the provider and patient advance visibility into what the payer is expected to cover.

CARC 101 is fundamentally different from a denial. No service has been rendered, no claim has been adjudicated, and no payment has been finalized. The payer is simply communicating: this is what we anticipate paying when you submit the actual claim. The predetermination amount is not a guarantee of payment — it is an estimate based on the patient's current eligibility, benefit structure, and the information provided in the predetermination request.

Predeterminations are most commonly used for high-cost procedures, dental services, and elective surgeries where advance cost information helps patients make informed decisions about their care. Some payers require predetermination for certain service categories before they will authorize the procedure. If the predetermination response is lower than expected or if the payer requests additional information, the provider should address those concerns before proceeding with the service to avoid payment surprises at the claim stage.

How to Resolve

Review the predetermination response, satisfy any outstanding requirements, and submit the actual claim with the predetermination reference number once services are rendered.

1. Note the anticipated amount for reference Record the predetermination estimate for patient cost discussions and financial planning. No financial posting is required at this stage.
2. Submit the actual claim when ready File the claim after services are rendered and include the predetermination reference. Both primary and secondary payers will adjudicate based on actual service and eligibility data.

How to Prevent OA-101

• Submit predetermination requests to all relevant payers in a COB scenario to get a complete picture of anticipated coverage
• Coordinate predetermination timelines across payers to avoid delays in service delivery

Also Filed As

The same CARC 101 may appear with different Group Codes:

Related Denial Codes