OA-160: Benefit Exclusion — Activity-Related Injury/Illness

What Does OA-160 Mean?

OA-160 signals a coordination of benefits situation where the activity-related injury should be covered by another payer, such as auto insurance, workers' compensation, or a liability insurer. The OA group code indicates neither the provider nor the patient should absorb the cost under this plan — the claim should be directed to the responsible payer.

When CARC 160 appears on a remittance, the payer has determined that the patient's injury or illness was caused by an activity that falls under the benefit exclusion clause of their insurance plan. Common examples include injuries sustained during extreme sports (skydiving, bungee jumping, hang gliding), participation in illegal activities, or self-inflicted harm. The payer is not questioning whether the medical service was appropriate — it is stating that the plan does not cover injuries arising from that particular activity.

This code is driven by the ICD-10 external cause codes on the claim and the clinical documentation describing how the injury occurred. Payers use these codes to match the circumstances of the injury against their plan's exclusion list. If the external cause coding inadvertently links the injury to an excluded activity — say, using a recreation-related code when the patient simply tripped at home — the denial may be a coding error rather than a legitimate exclusion.

The financial impact depends on the group code. CO-160 is a contractual write-off: the provider absorbs the loss and cannot bill the patient. PR-160 shifts the balance to the patient, who is responsible for the full amount because their plan explicitly excludes coverage for the activity in question. In either case, if another insurer should be primary (auto insurance, workers' compensation, liability insurer), you may be able to redirect the claim to that payer. OA-160 appears less frequently and usually signals a coordination of benefits situation where another payer or program is the appropriate source of payment.

How to Resolve

Verify the activity exclusion is correctly applied, then either correct coding errors and resubmit, collect from the patient, or redirect to the appropriate liability insurer.

1. Identify the responsible payer Determine which insurer should cover the activity-related injury (auto, workers' comp, liability). Review the patient's coverage and the circumstances of the injury.
2. Submit to the correct payer Redirect the claim to the identified payer with all required documentation and proof of the injury circumstances.
3. Request reprocessing if OA was applied in error If no other payer is responsible, contact the original payer with documentation and request the claim be reprocessed under the correct group code.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-160:

How to Prevent OA-160

• Identify coordination of benefits issues during patient intake by asking about other insurance coverage
• Verify which payer is primary for activity-related injuries before submitting claims
• Document all payer information and liability determinations in the patient's account

Also Filed As

The same CARC 160 may appear with different Group Codes:

Related Denial Codes