CARC 45 Active

OA-45: Charge Exceeds Fee Schedule/Maximum Allowable

TL;DR

Adjustment in a COB or secondary payer context. Review the coordination of benefits details to determine the responsible party.

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-45 Mean?

With OA (Other Adjustments), CARC 45 typically appears in a coordination of benefits (COB) context. Secondary payer applies its own fee schedule reduction. The financial responsibility depends on the specific arrangement between payers — review the primary payer's EOB and the COB terms to determine the correct course of action.

CARC 45 means the payer adjusted the payment based on charge exceeds fee schedule/maximum allowable. The reimbursement was calculated using the payer's fee schedule, contracted rate, or regulatory payment methodology rather than the billed charge.

Common scenarios that trigger this adjustment include: the provider's charge exceeds the contracted fee schedule rate with the payer; Charges exceed the Medicare Physician Fee Schedule (MPFS) allowed amount; The billed amount is higher than the payer's maximum allowable for the service. The group code paired with CARC 45 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

Cause Frequency
Fee schedule adjustment in secondary context Secondary payer applies its own fee schedule reduction Most Common

How to Resolve

  1. Review the coordination of benefits Examine the OA-45 adjustment to understand how it fits within the primary/secondary payer relationship or other multi-payer context.
  2. Verify primary payer adjudication Review the primary payer's EOB to understand the basis for the secondary payer's OA adjustment.
  3. Determine the responsible party Based on the COB review, identify whether the adjustment should be absorbed, billed to another payer, or if additional documentation is needed.
  4. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Do Not Appeal This Code

OA-45 reflects the secondary payer's fee schedule adjustment. Write off the difference per the contract.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-45:

RARC Description
N14 Payment based on contractual amount Review secondary payer fee schedule →
N381 Consult contract for payment information Verify secondary payer contract terms →

How to Prevent OA-45

Also Filed As

The same CARC 45 may appear with different Group Codes:

CO-45 PR-45

Related Denial Codes

OA-24 — Charges Covered Under Capitation/Managed Care OA-44 — Prompt-Pay Discount OA-69 — Day Outlier Amount OA-70 — Cost Outlier Adjustment OA-271 — Prior Contractual Reductions on Current Payment Schedule

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/45
  3. https://www.athelas.com/tbh/decoding-carc-code-45-navigating-fee-schedule-denials-in-medical-billing
  4. https://cms.officeally.com/blog/understanding-claim-response-codes-co-45-and-n381
  5. Codes maintained by X12. Visit x12.org for official definitions.