CARC 280 Active

OA-280: Claim Received but Benefits Not Covered — Submit to Pharmacy Plan

TL;DR

The medical plan adjusted the claim because it belongs under the pharmacy benefit. Resubmit to the patient's pharmacy plan.

Action
Resubmit
Who Pays
Depends
Appeal
No
Patient Impact
Indirect
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does OA-280 Mean?

OA-280 is an adjustment indicating the medical plan cannot process the service because it belongs to the pharmacy benefit. The adjustment redirects the claim to the pharmacy plan without assigning responsibility to provider or patient.

CARC 280 is a redirection, not a true denial. The medical plan received the claim and determined that the billed services — typically medications, infusion therapies, or specialty drugs — fall under the patient's pharmacy benefit rather than the medical benefit. The payer is instructing you to submit the claim to the patient's pharmacy benefit manager (PBM) instead.

This situation is increasingly common as health plans carve out pharmacy benefits from medical benefits. Self-administered specialty medications, certain injectable drugs, and some infusion therapies may be covered under the pharmacy benefit even when administered in a clinical setting. The medical plan simply cannot adjudicate these claims because the coverage sits with the PBM.

Note the distinction between CARC 280 and CARC 292: use 280 when the medical plan did not forward the claim to the pharmacy plan, and 292 when the claim was automatically forwarded. With 280, you need to handle the resubmission to the pharmacy plan yourself.

Common Causes

Cause Frequency
Medical-pharmacy benefit split The plan design places certain services under the pharmacy benefit, and the medical plan adjusts the claim to redirect to the pharmacy plan Most Common
Coverage determination requires pharmacy plan review The medical plan cannot determine coverage and directs the claim to the pharmacy plan for adjudication Common

How to Resolve

Obtain the patient's pharmacy plan information and resubmit the claim to the pharmacy benefit manager.

  1. Confirm the redirection Review the adjustment to confirm the service belongs under the pharmacy benefit.
  2. Obtain pharmacy plan details Get the patient's PBM information and resubmit the claim to the pharmacy plan.
  3. Follow up Monitor the pharmacy plan submission and escalate if coverage is unclear.
Do Not Appeal This Code

OA-280 redirects the claim to the pharmacy benefit. Resubmit to the pharmacy plan rather than filing an appeal.

How to Prevent OA-280

General Prevention

Also Filed As

The same CARC 280 may appear with different Group Codes:

CO-280

Related Denial Codes

OA-23 — Impact of Prior Payer Adjudication OA-32 — Patient Not Eligible as Dependent OA-35 — Lifetime Benefit Maximum Reached OA-49 — Routine/Preventive Exam Not Covered OA-78 — Non-Covered Days / Room Charge Adjustment

Sources

  1. https://www.mdclarity.com/denial-code/280
  2. https://x12.org/codes/claim-adjustment-reason-codes
  3. Codes maintained by X12. Visit x12.org for official definitions.