OA-49: Non-Covered Routine/Preventive Exam

What Does OA-49 Mean?

With OA (Other Adjustments), CARC 49 typically appears in a coordination of benefits (COB) context. Secondary payer does not cover the preventive service. 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 49 indicates non-covered routine/preventive exam. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: the patient's insurance plan does not cover the routine or preventive exam that was billed; A diagnostic or screening procedure performed during a routine exam was denied because it was considered part of the preventive visit; The preventive exam exceeds the plan's allowed frequency (e.g., only one annual wellness visit per year). The group code paired with CARC 49 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

How to Resolve

1. Review the coordination of benefits Examine the OA-49 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. Appeal or resubmit if needed Appeal citing preventive care coverage requirements.
5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-49:

How to Prevent OA-49

• Verify across all payers

Also Filed As

The same CARC 49 may appear with different Group Codes:

Related Denial Codes