CARC 238 Active

OA-238: Claim Spans Eligible/Ineligible Periods - Ineligible Reduction

TL;DR

The eligibility split was applied during COB. Verify dates and submit the ineligible portion to the appropriate payer.

Action
Review & Decide
Who Pays
Depends
Appeal
No
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-238 Mean?

With OA, the eligible/ineligible split was applied during coordination of benefits.

CARC 238 indicates that the claim covers a date range that includes both dates when the patient was eligible for coverage and dates when they were not. The payer reduced the payment to cover only the eligible portion and excluded the ineligible dates. This commonly occurs with inpatient stays or ongoing service episodes where the patient's coverage started or ended during the service period.

For example, if a patient was admitted on January 15 but their coverage did not begin until January 20, the payer would reduce payment to cover only January 20 onward. The provider may need to bill the patient separately for the ineligible dates.

How to Resolve

  1. Verify eligibility dates across payers Check which payer covers which dates.
  2. Submit to the appropriate payer Direct the ineligible portion to the payer that covers those dates.
Do Not Appeal This Code

Claim Spans Eligible/Ineligible Periods - Ineligible Reduction grouped under OA is an Other Adjustment that doesn't fall into the standard contractual write-off or patient responsibility categories. Whether action is needed depends on the specific reason — review any accompanying RARC codes and payer guidance to decide whether this is a final adjustment to accept or an issue to resolve through resubmission.

How to Prevent OA-238

Also Filed As

The same CARC 238 may appear with different Group Codes:

PR-238 CO-238

Related Denial Codes

OA-74 — Indirect Medical Education Adjustment OA-75 — Direct Medical Education Adjustment OA-76 — Disproportionate Share Adjustment OA-85 — Patient Interest Adjustment OA-89 — Professional Fees Removed from Charges

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  3. https://www.aapc.com/resources/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.