CARC 78 Active

OA-78: Non-Covered Days / Room Charge Adjustment

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-78 Mean?

When paired with Group Code OA, CARC 78 (Non-Covered Days / Room Charge Adjustment) is processed as an adjustment outside the standard CO/PR classifications. This typically occurs in secondary payer or coordination of benefits scenarios. Review the remittance details and the COB arrangement to determine financial responsibility and appropriate next steps.

CARC 78 indicates non-covered days / room charge adjustment. 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 determines that the patient's inpatient stay exceeded what is medically necessary based on clinical criteria, and the excess days are denied as non-covered; The provider did not obtain or renew prior authorization for continued inpatient days, resulting in the unauthorized days being denied; The patient was placed in a private room when only semi-private room charges are covered, and the difference is adjusted as non-covered. The group code paired with CARC 78 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.

How to Resolve

  1. Review the coordination of benefits Examine the OA-78 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 If the OA adjustment appears incorrect based on the COB arrangement, submit an appeal or corrected claim with the appropriate documentation.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Do Not Appeal This Code

Non-Covered Days / Room Charge Adjustment reflects a coverage determination — the service falls outside the plan's covered benefits as written. Coverage carve-outs per the plan terms aren't typically reversible by appeal; review the plan documentation and accept the adjustment if the determination matches the plan.

How to Prevent OA-78

Also Filed As

The same CARC 78 may appear with different Group Codes:

CO-78 PR-78

Related Denial Codes

OA-19 — Workers' Compensation Claim OA-20 — Liability Carrier Responsible OA-21 — No-Fault Carrier Responsible OA-22 — Coordination of Benefits - Another Payer May Cover OA-23 — Prior Payer Adjudication Impact

Sources

  1. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/78
  4. Codes maintained by X12. Visit x12.org for official definitions.