Health Insurance Adjustment Codes Overview

What is the purpose of using the OA (133) adjustment code?

When should the OA (257) adjustment code be used?

What should occur after the service line is finalized for an adjustment with the OA (133) code?

In which Loop is OA (133) code used?

What happens once the grace period ends for the OA (257) adjustment code?

What could lead to denial due to insufficient information?

Which reason for denial is specifically tied to conditions that existed before policy coverage?

What is a potential consequence of late filing of claims?

Which denial reason pertains to services not recognized by the insurance policy?

What can occur if a claim is submitted more than once without resolving the initial denial?

Other Adjustments (OA) Code 133

Disposition: Pending further review.
Group Code: OA.
Usage: Used only in the Loop 2110 CAS segment of the 835 or Loop 2430 of the 837.
Requirement: Requires a reversal and correction when the service line is finalized.

Other Adjustments (OA) Code 257

Disposition: Undetermined during the premium payment grace period.
Group Code: OA.
Usage: Used for claims/services in the grace period as per Health Insurance Exchange requirements.
Requirement: Automatically reversed and corrected when the grace period ends, based on premium payment status.

Denial due to Insufficient Information

Incomplete claims submissions are a common reason for claim denial.
Missing information can prevent insurance companies from accurately processing claims.

Pre-existing Health Conditions

Pre-existing health conditions are a potential reason for claim denial.
Insurance policies may have limitations or exclusions for conditions present before coverage began.

Late Filing of Claims

Submitting claims after the policy's deadline can lead to automatic denial.
Insurance companies have specific timeframes for filing claims, and exceeding them may result in rejection.

Non-covered Services

Insurance policies may not cover all medical services.
Claims for services not included in the policy coverage will be denied.

Duplicate Claim Submission

Submitting the same claim multiple times without resolving the initial denial can result in further denial due to duplicate submission.
This highlights the importance of addressing initial denial reasons and avoiding duplicate submissions.

Explore the details of Other Adjustments (OA) Codes 133 and 257 as they relate to health insurance claims. This quiz covers the specific usages, dispositions, and requirements for each code, along with their implications during the claims process. Test your understanding of how these codes function during various payment scenarios.