OA-292: Medical Plan Benefits Not Available - Forwarded to Pharmacy

What Does OA-292 Mean?

When CARC 292 appears with OA, the medical plan is routing the claim to the pharmacy plan without assigning financial liability. This is the most common pairing because the code is informational, indicating the claim is in transit. Financial responsibility will be determined by the pharmacy plan's adjudication. In the OA context, this adjustment typically relates to coordination of benefits between a primary and secondary payer, where the financial responsibility is determined through the COB process.

CARC 292 indicates the medical plan received the claim, determined the service falls under the pharmacy benefit rather than the medical benefit, and has forwarded the claim to the patient's pharmacy plan for processing. This is a routing code that signals the claim is being redirected, not permanently denied.

This code most commonly appears for injectable or infusible medications, specialty drugs, and certain pharmacy-related services that some plans manage through a pharmacy benefit manager (PBM) rather than through the medical benefit. The split between medical and pharmacy benefits varies significantly by payer and plan design. Some plans cover certain drugs under the medical benefit when administered in a provider's office, while others route all drug claims through the pharmacy benefit regardless of setting.

The distinction between CARC 292 and CARC 280 is important: CARC 292 confirms the claim was forwarded to the pharmacy plan, while CARC 280 indicates the medical plan denied the claim without forwarding it. Providers should track the forwarded claim with the pharmacy plan to ensure it does not fall through the cracks during the routing process.

How to Resolve

1. Confirm receipt by pharmacy plan Contact the pharmacy plan or PBM within 7 days to verify the forwarded claim was received.
2. Submit directly if needed If the pharmacy plan has no record, submit the claim directly through the pharmacy plan's preferred submission channel with NDC codes and administration records.

How to Prevent OA-292

• Verify whether the service or drug falls under the medical or pharmacy benefit before initial submission
• Check the patient's pharmacy benefit coverage during eligibility verification

Also Filed As

The same CARC 292 may appear with different Group Codes:

Related Denial Codes