CARC 287 Active

OA-287: Referral Exceeded

TL;DR

OA-287: 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-287 Mean?

When paired with Group Code OA, CARC 287 typically appears in a secondary payer or coordination of benefits context. The adjustment for referral exceeded is being processed through COB rules. The financial responsibility depends on the specific coordination arrangement between payers.

CARC 287 fires when the number of visits or services provided under a referral exceeds the authorized limit. Every referral has boundaries — a maximum number of visits, a date range, or both. Once those limits are reached, any additional services under that referral will be denied.

This denial is common in managed care plans (HMOs and some PPOs) that require referrals from a primary care physician before patients can see specialists. The referral typically authorizes a specific number of visits (e.g., 6 physical therapy sessions) or is valid for a limited time period (e.g., 90 days). When the provider continues treating the patient beyond those limits without obtaining a new or extended referral, CARC 287 results.

The financial impact depends on the Group Code. Under CO, the provider should have tracked the referral and obtained an extension before the limit was reached — they absorb the cost. Under PR, the patient is responsible because they continued scheduling appointments after being informed the referral was exhausted, or they failed to obtain a new referral from their PCP as required by their plan.

How to Resolve

  1. Review the coordination of benefits Examine the OA-287 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

Referral Exceeded reflects an authorization or referral issue. The standard path is not an appeal but a request for retroactive authorization through the payer's process — appeals only apply when authorization was obtained but the payer failed to record it. Gather the authorization documentation if available; otherwise the adjustment usually stands.

How to Prevent OA-287

Also Filed As

The same CARC 287 may appear with different Group Codes:

CO-287 PR-287

Related Denial Codes

OA-39 — Services Denied at Authorization/Pre-certification OA-61 — Failure to Obtain Second Surgical Opinion OA-197 — Precertification/Authorization/Notification Absent OA-198 — Precertification/Authorization Limits Exceeded OA-210 — Pre-Certification/Authorization Not Received Timely

Sources

  1. https://www.mdclarity.com/denial-code/287
  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.