CARC 23 Active

OA-23: Prior Payer Adjudication Impact

TL;DR

Adjustment in a COB or secondary payer context. Review the coordination of benefits details to determine the responsible party.

Action
Review & Decide
Who Pays
Depends
Appeal
Yes
Patient Impact
Indirect
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does OA-23 Mean?

When paired with Group Code OA, CARC 23 (Prior Payer Adjudication Impact) 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 23 indicates prior payer adjudication impact. 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: secondary payer applies its own fee schedule or contractual adjustments after the primary payer's payment; Primary payer's payment exceeded the secondary payer's allowable, resulting in no additional payment; Adjustments from the primary payer are applied to the secondary claim processing. The group code paired with CARC 23 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.

Common Causes

Cause Frequency
General prior payer impact Adjustment reflecting the overall impact of primary payer's adjudication Most Common

How to Resolve

  1. Review the coordination of benefits Examine the OA-23 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 Appeal with both payer EOBs if the OA adjustment appears to be incorrectly calculated.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Appeal Guide

Appeal with both payer EOBs if the OA adjustment appears to be incorrectly calculated.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-23:

RARC Description
MA04 Secondary payment cannot be considered without primary payer information Provide complete primary payer EOB →

How to Prevent OA-23

Also Filed As

The same CARC 23 may appear with different Group Codes:

CO-23 PR-23

Related Denial Codes

OA-22 — Coordination of Benefits - Another Payer May Cover OA-1 — Deductible Amount OA-2 — Coinsurance Amount OA-195 — Refund to Erroneous Priority Payer OA-19 — Workers' Compensation Claim

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.