OA-190: Payment Included in SNF Qualified Stay Allowance

What Does OA-190 Mean?

OA-190 is less common and appears when the SNF bundling determination requires further review, or when the adjustment involves a coordination issue between the SNF and the outside provider. This may also occur when the patient's SNF stay status is unclear.

CARC 190 appears on your remittance when the payer determines that the billed service is part of the Skilled Nursing Facility's consolidated billing package and cannot be reimbursed separately. Under Medicare's SNF Prospective Payment System (PPS), the SNF receives a bundled per diem rate that covers virtually all services the patient receives during a qualified stay — including therapy, medications, lab tests, and supplies.

This denial most commonly hits outside providers who furnish services to SNF patients without realizing that the service is included in the SNF's payment. For example, a lab company that draws and processes bloodwork for an SNF patient, or a therapy provider who renders services at the facility, may bill the payer directly only to discover that the service was already covered under the SNF's rate. The SNF is responsible for paying these providers from its per diem payment.

There are important exceptions. Certain services are excluded from SNF consolidated billing and can be billed separately — including physician professional services, certain dialysis services, specific ambulance transports, and some high-cost imaging. The SNF consolidated billing exclusion list maintained by CMS specifies exactly which services can be separately billed. If your service is on the exclusion list, the denial may be in error and you can resubmit with the appropriate modifiers and documentation.

How to Resolve

Determine if the service is included in the SNF consolidated billing bundle or qualifies for separate billing under the CMS exclusion list, then either write off the claim or resubmit with correct coding.

1. Verify SNF stay dates Confirm the exact dates of the patient's qualified SNF stay with both the payer and the SNF to determine if consolidated billing applies.
2. Contact the payer Request clarification on the bundling determination and whether the service qualifies for separate billing under any exclusion provision.

How to Prevent OA-190

• Verify the patient's SNF stay status with the payer before submitting claims for services rendered during the SNF stay period
• Coordinate with the SNF's billing department to avoid conflicting claims

Also Filed As

The same CARC 190 may appear with different Group Codes:

Related Denial Codes