OA-167: Diagnosis Not Covered

What Does OA-167 Mean?

When paired with Group Code OA, CARC 167 (Diagnosis Not Covered) 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 167 indicates diagnosis not covered. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: the patient's insurance plan specifically excludes coverage for the submitted diagnosis, such as cosmetic conditions, certain mental health diagnoses, or experimental conditions; While the diagnosis itself may be covered, the payer does not consider it a covered indication for the specific procedure or service that was billed; The diagnosis code submitted does not accurately represent the patient's condition, and the code used happens to be excluded from coverage. The group code paired with CARC 167 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

How to Resolve

1. Review the coordination of benefits Examine the OA-167 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.

How to Prevent OA-167

• Maintain accurate coordination of benefits information
• Verify secondary payer requirements before claim submission

Also Filed As

The same CARC 167 may appear with different Group Codes:

Related Denial Codes