CARC 275 Active

OA-275: Prior Payer Patient Responsibility Not Covered

TL;DR

OA-275: This adjustment involves secondary payer processing or coordination of benefits. Review the COB arrangement and primary payer adjudication to determine the appropriate action.

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-275 Mean?

When paired with Group Code OA, CARC 275 typically appears in a secondary payer or coordination of benefits context. The adjustment for prior payer patient responsibility not covered is being processed through COB rules. The financial responsibility depends on the specific coordination arrangement between payers.

CARC 275 appears in multi-payer scenarios — typically when a secondary or tertiary payer processes a claim and determines that the patient responsibility amount left by the prior payer is not covered under their plan. The patient's deductible, coinsurance, or copayment from the primary payer remains the patient's obligation.

This code is exclusively used with Group Code PR, making it clear that the patient bears the financial responsibility. It most commonly surfaces on claims where the primary payer has already adjudicated and left a balance that the patient expected the secondary plan to pick up. In practice, many patients with dual coverage assume the secondary payer will cover whatever the primary did not, but that is not always the case.

Before billing the patient, verify that the coordination of benefits information is accurate across both payers. Incorrect patient demographics or COB data can cause the secondary payer to inappropriately deny coverage of the patient responsibility amount.

How to Resolve

  1. Review the coordination of benefits Examine the OA-275 adjustment and determine how it fits within the primary/secondary payer relationship.
  2. Verify primary payer adjudication Review the primary payer's EOB to understand the basis for the secondary payer's OA adjustment.
  3. Determine appropriate action Based on the COB review, decide whether to accept the adjustment, submit additional documentation, or file an appeal with the secondary payer.
  4. Follow up Monitor the claim and take additional action as needed based on the COB determination.
Do Not Appeal This Code

Prior Payer Patient Responsibility Not Covered reflects a coverage determination — the service falls outside the plan's covered benefits as written. Coverage carve-outs per the plan terms aren't typically reversible by appeal; review the plan documentation and accept the adjustment if the determination matches the plan.

How to Prevent OA-275

Also Filed As

The same CARC 275 may appear with different Group Codes:

PR-275 CO-275

Related Denial Codes

OA-19 — Workers' Compensation Claim OA-20 — Liability Carrier Responsible OA-21 — No-Fault Carrier Responsible OA-22 — Coordination of Benefits - Another Payer May Cover OA-23 — Prior Payer Adjudication Impact

Sources

  1. https://www.mdclarity.com/denial-code/275
  2. https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
  3. https://x12.org/codes/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.