OA-213: Physician Self-Referral Prohibition Violation

What Does OA-213 Mean?

OA-213 may appear when the self-referral issue requires further investigation or involves a coordination of benefits scenario. The financial responsibility depends on the outcome of the compliance review.

CARC 213 is a compliance-focused denial that flags claims where the referring physician may have a financial interest in the entity providing the service. This code is rooted in the Physician Self-Referral Law (Stark Law), which prohibits physicians from referring Medicare patients for designated health services to entities in which they have a financial relationship, unless a specific exception applies.

This denial carries serious implications beyond the immediate revenue loss. A pattern of CARC 213 denials can trigger payer audits, compliance investigations, and potential legal liability under the False Claims Act. The financial relationships that trigger this code include ownership or investment interests in the service entity and compensation arrangements that create referral incentives.

However, Stark Law has numerous exceptions — the in-office ancillary services exception, the fair market value exception, and the electronic health records exception among them. Many CARC 213 denials can be resolved by documenting that a valid exception applies. The key is whether the provider can produce evidence of compliance. Without that documentation, the denial stands and the provider absorbs the full cost.

How to Resolve

Determine whether a valid Stark Law exception applies to the referral arrangement, document compliance, and appeal with supporting evidence.

1. Conduct compliance review Audit the referral relationship and provide the payer with compliance documentation or acknowledge the violation.

How to Prevent OA-213

• Proactively disclose financial relationships and document applicable exceptions before claims are submitted

Also Filed As

The same CARC 213 may appear with different Group Codes:

Related Denial Codes