OA-P5: Reasonable and Customary Fee Adjustment — P&C Only

What Does OA-P5 Mean?

CARC P5 applies exclusively to property and casualty claims and indicates the payer adjusted the charges to match reasonable and customary (R&C) rates for the service in the provider's geographic area. This code appears when no state-legislated fee schedule applies, so the payer applies its own R&C methodology.

R&C determinations are based on surveys of prevailing charges in the geographic area. If your charges exceed the payer's R&C rate, the difference is adjusted. Unlike state fee schedule adjustments (P12), R&C rates are set by the individual payer rather than by statute, which makes them more negotiable.

Disputing an R&C determination typically involves providing evidence of prevailing charges in your area from fee surveys, published databases, or comparable payer reimbursement data showing the payer's R&C rate is below market.

Common Causes

How to Resolve

Verify the R&C rate against prevailing charges and dispute if the rate is below market.

1. Review the R&C determination Check the allowed amount against the payer's R&C rate for the service and geographic area.
2. Gather prevailing charge data Collect fee survey data, published databases, and reimbursement rates from other P&C payers for the same service.
3. Dispute with documentation Submit a fee dispute with prevailing charge evidence showing the R&C rate should be higher.
4. Negotiate with the adjuster Contact the P&C adjuster directly to negotiate a fair rate based on market data.

How to Prevent OA-P5

• Track R&C rate changes across P&C payers
• Maintain competitive pricing aligned with area standards

Also Filed As

The same CARC P5 may appear with different Group Codes:

Related Denial Codes