OA-95: Plan Procedures Not Followed

What Does OA-95 Mean?

OA-95 is uncommon and typically appears in coordination of benefits scenarios where the plan procedure violation does not fall cleanly into provider or patient responsibility. The primary payer may use OA to indicate that the plan procedure issue should be evaluated in the context of a secondary payer's requirements.

When CARC 95 appears on a remittance, the payer is telling you that someone — either the provider or the patient — did not follow a required procedural step outlined in the insurance plan before the service was delivered. This is one of the most preventable denial codes in medical billing because it almost always traces back to a verification gap in the pre-service workflow.

The most frequent trigger is a missing prior authorization. The payer required pre-approval for the service, and the authorization was not obtained before care was rendered. Missing referrals are the second most common cause, particularly for plans that require a primary care physician referral before the patient can see a specialist. Non-compliance with step therapy protocols, where the payer requires the patient to try lower-cost treatments before more expensive ones, is another trigger.

The group code paired with CARC 95 determines the financial impact. CO-95 places the responsibility on the provider — you rendered the service without following the required plan procedure, and your contract holds you liable. PR-95 places it on the patient — they sought care without obtaining their plan's required referral or following other member-side procedures. In both cases, the accompanying RARC code will specify exactly which plan procedure was not followed, so always read the remark code before deciding on your resolution strategy.

How to Resolve

Identify the specific plan procedure that was missed, attempt to satisfy it retroactively, and either resubmit or appeal with supporting documentation.

1. Check secondary payer requirements Verify whether the secondary payer has its own authorization or referral requirements that may differ from the primary payer's.
2. Submit to the secondary payer File the claim with the secondary payer, including the primary ERA, and ensure any required authorizations or referrals are in place for the secondary plan.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-95:

How to Prevent OA-95

• Verify authorization and referral requirements for both primary and secondary payers before rendering services
• Maintain a tracking system for plan procedure requirements across all payers the patient is enrolled with

Also Filed As

The same CARC 95 may appear with different Group Codes:

Related Denial Codes