CARC 61 Active

OA-61: Failure to Obtain Second Surgical Opinion

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-61 Mean?

With OA (Other Adjustments), CARC 61 typically appears in a coordination of benefits (COB) context. Secondary payer requires second surgical opinion. 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 61 relates to failure to obtain second surgical opinion. The payer requires specific authorization, certification, or referral for this service, and the claim was adjusted because that requirement was not satisfied.

Common scenarios that trigger this adjustment include: the patient's plan requires a second surgical opinion before certain procedures and it was not obtained; A second opinion was obtained but documentation was not submitted with the claim; Specific payers or plan types mandate a second opinion for elective surgeries. The group code paired with CARC 61 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 second opinion requirement Secondary payer requires second surgical opinion Most Common

How to Resolve

  1. Review the coordination of benefits Examine the OA-61 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 second opinion documentation or emergency exemption.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Appeal Guide

Appeal with second opinion documentation or emergency exemption.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-61:

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

How to Prevent OA-61

Also Filed As

The same CARC 61 may appear with different Group Codes:

CO-61 PR-61

Related Denial Codes

OA-1 — Deductible Amount OA-2 — Coinsurance Amount OA-3 — Co-payment Amount OA-24 — Charges Covered Under Capitation/Managed Care OA-40 — Charges Do Not Meet Emergent/Urgent Care Qualifications

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.