OA-204: Service/Equipment/Drug Not Covered Under Benefit Plan

What Does OA-204 Mean?

With OA (Other Adjustments), the non-coverage was identified during coordination of benefits. One payer does not cover the service, but another payer in the COB chain may provide coverage. Submit to the other payer.

CARC 204 indicates that the billed service, drug, or equipment is explicitly excluded from the patient's benefit plan. Unlike denials for medical necessity (where the service type is covered but the specific use was not justified), this code means the entire category of service or specific item is not part of the plan's covered benefits.

This denial commonly occurs when a medication is not on the plan's formulary, DME is excluded from the benefit package, the plan has a benefit cap that has been reached, or the service requires prior authorization that was not obtained. Understanding the specific reason for non-coverage is essential for determining the correct resolution path.

Common Causes

How to Resolve

1. Check other payers Verify whether another payer in the coordination chain covers the service.
2. Submit to the covering payer If another payer covers the service, submit the claim accordingly.
3. Appeal if appropriate If the service should be covered, appeal with documentation.

How to Prevent OA-204

• Verify coverage across all payers in the coordination of benefits before service delivery
• Confirm which payer is primary for the specific service type

Also Filed As

The same CARC 204 may appear with different Group Codes:

Related Denial Codes