OA-215: Third Party Subrogation Settlement

What Does OA-215 Mean?

OA-215 appears in multi-payer coordination situations where the subrogation settlement affects the primary payer's adjudication but leaves a balance that may be payable by another payer. The adjustment under OA signals that the responsibility for the remaining amount needs to be determined by a subsequent payer rather than being written off or billed to the patient. This commonly occurs when the liability carrier's settlement does not fully cover the charges.

When CARC 215 appears on a remittance, the payer has determined that a third party liability settlement — such as a workers compensation settlement, auto insurance settlement, or personal injury settlement — has already provided payment or is expected to provide payment for the services you billed. Subrogation is the legal process by which a health insurer recovers costs from a liable third party, and CARC 215 signals that the payer believes the third party settlement supersedes or reduces its own payment obligation for the claim.

This code is most frequently encountered in injury-related cases where a patient received treatment for injuries caused by another party's negligence — motor vehicle accidents, workplace injuries, slip-and-fall incidents, and similar liability situations. The payer may have placed a subrogation lien on the claim or may have received notification that a settlement was reached, prompting the adjustment. The key question you need to answer is whether the settlement actually covers the specific services and dates of service on the denied claim.

CARC 215 almost always appears with Group Code CO (contractual obligation), meaning the provider must absorb the adjustment and cannot bill the patient for the denied amount. In some multi-payer coordination scenarios, it may appear with OA (other adjustment), indicating the balance should be submitted to another payer. Either way, do not bill the patient without first verifying the settlement scope and confirming the appropriate next step with the payer's subrogation department.

Common Causes

How to Resolve

Determine whether the third party settlement actually covers the billed services, then either write off the amount or appeal with documentation showing the services fall outside the settlement scope.

1. Identify all payers in the billing sequence Determine the complete coordination of benefits order — liability carrier, primary health plan, secondary health plan — and identify which payer issued the OA-215 adjustment.
2. Contact the liability carrier Verify the settlement amount and confirm which services and charges are covered by the third party settlement. Request documentation of the settlement terms.
3. Submit to the next payer File the claim with the next responsible payer in the COB sequence, attaching the primary payer's ERA showing the OA-215 adjustment and the settlement documentation. The secondary payer will determine their payment responsibility for the remaining balance.
4. Track through final adjudication Monitor the claim through all payers in the sequence. Once all payers have adjudicated, determine if any patient responsibility remains and bill accordingly.

How to Prevent OA-215

• Establish workflows to identify third party liability cases early and coordinate billing across all involved payers from the start
• Maintain communication with the patient's attorney or third party administrator to stay informed of settlement progress and amounts
• Submit claims in the correct payer sequence and wait for each payer's adjudication before moving to the next

General Prevention

• Establish workflows to identify and track third party liability cases from the point of patient intake
• Coordinate with the patient's attorney or third party administrator to stay informed of settlement progress
• Document all communications with liability carriers and third party administrators

Also Filed As

The same CARC 215 may appear with different Group Codes:

Related Denial Codes