OA-245: Provider Performance Program Withhold

What Does OA-245 Mean?

OA-245 signals an interim performance withhold that is pending reconciliation at the end of the measurement period. Unlike CO-245, OA-245 does not necessarily represent a final adjustment — the withheld funds may be returned if the provider achieves performance targets by the end of the evaluation cycle. This Group Code is used when the withhold relates to a provisional assessment under a shared savings or risk-sharing arrangement rather than a definitive contractual write-off.

CARC 245 fires when a payer applies a payment reduction tied to a provider performance program — commonly a pay-for-performance (P4P), value-based purchasing, or shared savings arrangement. The withheld amount represents the performance-contingent portion of the reimbursement that the payer is holding back because the provider has not demonstrated compliance with the program's quality metrics, reporting obligations, or care protocol requirements.

This code is distinct from standard claim denials because it does not indicate a problem with the claim itself. The service was covered and approved — the payer simply reduced payment based on the provider's aggregate performance against contractual benchmarks. Common triggers include unmet HEDIS measures, below-threshold patient satisfaction scores, incomplete quality reporting submissions, or failure to follow evidence-based care pathways specified in the contract.

The financial impact of CARC 245 depends on the Group Code. CO-245 is the most common assignment, indicating a contractual write-off that the provider must absorb — the patient cannot be billed for the withheld amount. OA-245 may appear when the withhold is an interim adjustment pending year-end reconciliation, meaning the funds could be returned if the provider ultimately meets performance targets. Providers should track all performance withholds carefully, as many P4P programs reconcile at the end of the measurement period and return withheld amounts when benchmarks are achieved.

Common Causes

How to Resolve

Determine whether the withhold is based on accurate performance data, then either document compliance to recover funds or write off the adjustment as a contractual obligation.

1. Confirm interim status Review the remittance advice to verify the OA-245 adjustment is an interim withhold pending reconciliation, not a final denial. Confirm the measurement period and reconciliation timeline with the payer.
2. Verify the withhold calculation Compare the withheld amount against the performance program contract to ensure the withhold percentage and calculation are accurate.
3. Complete all quality submissions Ensure all required quality reports, outcome data, and performance attestations are submitted before the measurement period deadline. Missing submissions can prevent recovery of withheld amounts.
4. Follow up on reconciliation After the measurement period closes, contact the payer's performance program team to confirm the reconciliation timeline. Verify that earned incentive payments and returned withholds are processed correctly.

How to Prevent OA-245

• Understand the reconciliation timeline for each performance program and plan cash flow accordingly, knowing withheld amounts may be returned at year-end
• Maintain detailed records of all interim withholds by payer and program to verify against reconciliation payments
• Engage with the payer's performance program team proactively to understand interim standings and address metric gaps before the measurement period closes

General Prevention

• Understand the reconciliation timeline for each performance program and plan cash flow accordingly, knowing withheld amounts may be returned later
• Maintain accurate records of all interim withholds to verify against year-end reconciliation payments
• Engage with the payer's performance program team proactively to understand interim performance standings and address gaps before the measurement period closes

Also Filed As

The same CARC 245 may appear with different Group Codes:

Related Denial Codes