OA-288: Referral Absent / Missing Referral

What Does OA-288 Mean?

When CARC 288 appears with Group Code OA, the adjustment liability is not clearly assigned to either the provider or the patient. This typically occurs in coordination of benefits scenarios or when the payer uses OA as a general category. The provider should investigate whether the referral obligation falls on them or whether another party is responsible before deciding on next steps.

When CARC 288 appears on your remittance advice, the payer is telling you that the services billed required a referral from another physician, and that referral was either never obtained or was not included with the claim submission. Many managed care and HMO plans mandate that patients receive a referral from their primary care physician before seeing a specialist or receiving certain services. Without this referral on file, the payer will not process the claim.

This denial is distinct from a prior authorization denial. A referral is a recommendation from a PCP directing the patient to a specialist, while prior authorization is the payer's advance approval for a specific service. Some plans require both. CARC 288 specifically addresses the absence of the referral component. The denial may also trigger if the referral that was submitted has expired, was issued for the wrong provider, or contained incomplete information such as missing diagnosis codes or an unsigned form.

In most cases, CARC 288 appears with a CO group code, placing the financial responsibility on the provider. This is because obtaining and verifying the referral is considered part of the provider's administrative obligations before rendering services. The good news is that this denial is almost always recoverable if the referral can be obtained retroactively and the claim resubmitted within the payer's timely filing window.

How to Resolve

Obtain the missing referral documentation and resubmit the claim with the referral attached.

1. Determine liability Contact the payer to clarify whether the missing referral is the provider's responsibility, the patient's, or another insurer's under coordination of benefits.
2. Obtain the referral and resubmit Once liability is clarified, obtain the referral and resubmit the claim to the appropriate payer with all required documentation.

How to Prevent OA-288

• Clarify referral responsibility with all payers during contract negotiations
• Flag OA-coded denials for immediate follow-up to determine financial responsibility

Also Filed As

The same CARC 288 may appear with different Group Codes:

Related Denial Codes