OA-213: Non-Compliance with Physician Self-Referral Prohibition

What Does OA-213 Mean?

With OA (Other Adjustments), the self-referral issue appeared during coordination of benefits. Address the compliance issue and resubmit.

CARC 213 indicates that the payer determined the claim may involve a violation of the physician self-referral prohibition, commonly known as the Stark Law. This federal law prohibits physicians from referring Medicare and Medicaid patients for designated health services to entities with which they or their immediate family members have a financial relationship, unless a specific exception applies.

Designated health services under Stark include clinical laboratory services, radiology, physical therapy, DME, and several others. If a financial relationship exists between the referring physician and the service provider, and no exception applies, the claim cannot be paid.

Common Causes

How to Resolve

1. Address the compliance issue Verify Stark Law compliance for the referral.
2. Resubmit with documentation Submit exception documentation to the applicable payer.

How to Prevent OA-213

• Verify Stark Law compliance before submitting claims through any payer

General Prevention

• Maintain compliance with self-referral regulations across all payer relationships
• Document all qualifying exceptions proactively

Also Filed As

The same CARC 213 may appear with different Group Codes:

Related Denial Codes