OA-242: Services Not Provided by Network/Primary Care Providers

What Does OA-242 Mean?

With OA, the network issue was flagged during coordination of benefits. One payer's network requirements may differ from another's.

CARC 242 indicates that the service was rendered by a provider who is outside the patient's required network or is not the patient's designated primary care provider, and the patient's plan requires these services to come from network or PCP providers. This is common in HMO and gatekeeper plans where patients must use in-network providers and obtain services through or under the direction of their assigned primary care provider.

The denial means the plan does not cover services from out-of-network providers or non-PCP providers for this service type. The patient may need to receive the service from their designated network provider, or obtain a referral from their PCP.

Common Causes

How to Resolve

1. Check network status per payer Verify the provider's network participation with each payer.
2. Submit to the appropriate payer Direct the claim to the payer with whom the provider is in-network.

How to Prevent OA-242

• Verify network status with all payers before providing services

General Prevention

• Verify network status across all payers in the COB chain

Also Filed As

The same CARC 242 may appear with different Group Codes:

Related Denial Codes