CARC 55 Active

OA-55: Procedure/Treatment Deemed Experimental/Investigational

TL;DR

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

Action
Appeal
Who Pays
Depends
Appeal
Yes
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-55 Mean?

With OA (Other Adjustments), CARC 55 typically appears in a coordination of benefits (COB) context. Secondary payer classifies treatment as experimental. 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 55 indicates procedure/treatment deemed experimental/investigational. 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 payer's medical policy classifies the procedure, treatment, or drug as experimental or investigational; The payer determined there is insufficient clinical evidence that the treatment is effective for the patient's condition; Drug or device is used off-label for an indication not approved by the FDA. The group code paired with CARC 55 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
Secondary payer experimental exclusion Secondary payer classifies treatment as experimental Most Common

How to Resolve

  1. Review the coordination of benefits Examine the OA-55 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 with clinical evidence supporting the treatment.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Appeal Guide

Appeal with clinical evidence supporting the treatment.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-55:

RARC Description
N381 Consult contract/fee schedule Review secondary payer policy →

How to Prevent OA-55

Also Filed As

The same CARC 55 may appear with different Group Codes:

CO-55 PR-55

Related Denial Codes

OA-40 — Charges Do Not Meet Emergent/Urgent Care Qualifications OA-49 — Non-Covered Routine/Preventive Exam OA-51 — Non-Covered Pre-existing Condition OA-53 — Services by Immediate Relative Not Covered OA-54 — Multiple Physicians/Assistants Not Covered

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/55
  3. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  4. Codes maintained by X12. Visit x12.org for official definitions.