OA-167: Diagnosis Not Covered

What Does OA-167 Mean?

OA-167 is uncommon and typically appears in coordination of benefits situations where the diagnosis may be covered by a different payer. The OA group code signals that the responsibility is being shifted to another party rather than absorbed by the provider or patient.

When CARC 167 appears on a remittance, the payer has denied the claim because the diagnosis or diagnoses listed on the claim are not covered by the patient's insurance plan. The payer is not saying the service was coded incorrectly or that the provider is ineligible — it is specifically flagging the diagnosis itself as outside the plan's covered conditions.

However, a significant portion of CARC 167 denials are actually coding errors rather than genuine coverage exclusions. Industry data from Experian Health indicates that 42% of all claim denials are caused by coding inaccuracies. A missing 7th character on an ICD-10 code, an incorrect code that maps to a non-covered condition, or an outdated code set can all trigger CARC 167 when the underlying diagnosis is actually covered. Before accepting this denial at face value, always verify the coding accuracy against the clinical documentation.

When the denial is legitimate, it typically involves plan-specific exclusions for cosmetic conditions, experimental treatments, certain mental health conditions, fertility services, or pre-existing conditions under older plan types. The financial impact depends entirely on the group code. CO-167 is a contractual write-off that the provider absorbs. PR-167 shifts the balance to the patient, but only if proper advance notification (ABN for Medicare, or similar payer-specific waiver) was obtained before the service. The 835 Healthcare Policy Identification Segment (Loop 2110 REF) often points to the specific NCD, LCD, or payer policy behind the denial — checking this field can save significant research time.

How to Resolve

Verify the ICD-10 diagnosis code is accurate and specific, check plan coverage, and either correct and resubmit or appeal with clinical documentation.

1. Identify the responsible payer Determine whether the diagnosis is covered by a secondary payer, supplemental plan, or other coverage the patient has.
2. Submit to the correct payer Redirect the claim to the payer whose plan covers the submitted diagnosis.
3. Request reprocessing if OA was applied in error If no other payer is responsible and the OA assignment was incorrect, contact the payer and request the claim be reprocessed.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-167:

How to Prevent OA-167

• Verify which payer covers the diagnosis during eligibility checks before the visit
• Maintain accurate records of all patient coverage including secondary and supplemental plans
• Submit claims to the correct primary payer based on diagnosis coverage from the start

Also Filed As

The same CARC 167 may appear with different Group Codes:

Related Denial Codes