CARC 109 Active

OA-109: Claim Not Covered by This Payer

TL;DR

Adjustment in a COB or secondary payer context. Review the coordination of benefits details to determine the responsible party.

Action
Review & Decide
Who Pays
Depends
Appeal
No
Patient Impact
Indirect
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does OA-109 Mean?

When paired with Group Code OA, CARC 109 (Claim Not Covered by This Payer) is processed as an adjustment outside the standard CO/PR classifications. This typically occurs in secondary payer or coordination of benefits scenarios. Review the remittance details and the COB arrangement to determine financial responsibility and appropriate next steps.

CARC 109 appears on a remittance when the payer applies an adjustment for claim not covered by this payer. Review the group code and any accompanying RARC codes to understand the full context of this adjustment.

Common scenarios that trigger this adjustment include: the claim was sent to a MAC that does not have jurisdiction over the provider's geographic area or service type, and must be resubmitted to the correct MAC; The patient's insurance coverage is with a different plan or payer than the one the claim was submitted to; The specific service type (Part A vs. Part B, DME vs. professional) was submitted to a payer that does not process that category of claims. The group code paired with CARC 109 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

How to Resolve

  1. Review the coordination of benefits Examine the OA-109 adjustment to understand how it fits within the primary/secondary payer relationship or other multi-payer context.
  2. Verify primary payer adjudication Review the primary payer's EOB to understand the basis for the secondary payer's OA adjustment.
  3. Determine the responsible party Based on the COB review, identify whether the adjustment should be absorbed, billed to another payer, or if additional documentation is needed.
  4. Appeal or resubmit if needed If the OA adjustment appears incorrect based on the COB arrangement, submit an appeal or corrected claim with the appropriate documentation.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Do Not Appeal This Code

The claim was submitted to the wrong payer or contractor. Resubmit to the correct payer rather than appealing this determination.

How to Prevent OA-109

Also Filed As

The same CARC 109 may appear with different Group Codes:

CO-109 PR-109

Related Denial Codes

OA-19 — Workers' Compensation Claim OA-20 — Liability Carrier Responsible OA-21 — No-Fault Carrier Responsible OA-22 — Coordination of Benefits - Another Payer May Cover OA-23 — Prior Payer Adjudication Impact

Sources

  1. https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/109
  4. Codes maintained by X12. Visit x12.org for official definitions.