OA-78: Non-Covered Days / Room Charge Adjustment

What Does OA-78 Mean?

OA-78 appears in coordination of benefits scenarios where the primary payer's non-covered day adjustment is forwarded to a secondary payer. The secondary payer will evaluate the remaining balance under its own coverage terms.

When CARC 78 appears on a remittance, the payer is telling you that certain hospital days or room charges fall outside the scope of coverage. This is not a blanket claim denial — the payer may have paid for part of the stay and is adjusting specific dates that it considers non-covered.

The reasons behind CARC 78 vary significantly depending on the group code. Under CO, the non-covered days typically result from a payer's retrospective determination that the patient no longer met inpatient criteria on those dates, that the stay exceeded a contractual day limit, or that prior authorization lapsed before the patient was discharged. These are among the most frequently appealed inpatient adjustments because they often hinge on clinical judgment about medical necessity.

Under PR, the picture changes: the patient has exhausted their covered benefit days. For Medicare patients, this means all 90 standard days plus 60 lifetime reserve days per benefit period have been used. For commercial plans, it means the annual or per-admission day limit has been reached. PR-78 shifts the financial burden directly to the patient. The provider should verify the benefit day count, check for secondary coverage, and issue an Advance Beneficiary Notice if the exhaustion was foreseeable.

OA-78 appears less frequently, primarily in coordination of benefits scenarios. Tracking CARC 78 patterns by payer and service line helps identify systemic issues with authorization management, utilization review timing, or discharge planning.

How to Resolve

Identify which days were denied and why, verify the denial basis against coverage terms, then write off, appeal with clinical documentation, or bill the patient.

1. Submit to the secondary payer File a secondary claim with the primary ERA showing the OA-78 adjustment, along with complete clinical records for the denied dates.
2. Process the secondary ERA Review the secondary adjudication. If the secondary payer also denies, determine whether the remaining balance becomes a patient responsibility or requires further action.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-78:

How to Prevent OA-78

• Verify all insurance coverage at admission to ensure proper COB sequencing
• Submit secondary claims promptly when OA adjustments appear on primary remittances

Also Filed As

The same CARC 78 may appear with different Group Codes:

Related Denial Codes