OA-128 Denials Explained: How to Identify, Appeal, and Prevent Them

Denial codes can significantly disrupt healthcare revenue cycle operations, and OA-128 is no exception. If your team frequently encounters OA-128 denials, you're not alone. These denials occur when newborn care charges are bundled with the mother's hospital allowance, leaving no separate payment for the newborn's services.

In this article, you'll learn the key details about OA-128 denials, including how to identify them, appeal effectively, and implement strategies to prevent them. By understanding this denial code, RCM professionals can mitigate its impact and safeguard their organization's revenue integrity.

What Is a OA-128 Denial?

OA-128 is a denial code that indicates newborn services are bundled within the mother's hospital allowance, meaning no additional payment will be made for the newborn's care.

The “OA” prefix stands for “Other Adjustment,” signifying that the denial stems from a billing policy adjustment rather than patient responsibility or contractual obligations. In the case of OA-128, the payer assumes financial responsibility but denies payment for the newborn's services as they are included under the mother’s hospital charges.

Comparison: OA-128 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
OA-128	Other Adjustment	Newborn's services are covered in the mother's Allowance.	Payer
CO-96	Contractual Obligation	Charges exceed the provider’s contractually allowed amount.	Provider
PR-204	Patient Responsibility	Services not covered due to patient's policy exclusions.	Patient

OA-128 differs from CO-96 and PR-204 as it is not related to provider agreements or patient coverage limits but rather a bundling adjustment by the payer.

Common Causes of OA-128 Denials

1. Incorrect Billing for Newborn Services: Submitting separate claims for newborn care without acknowledging payer bundling policies.
2. Lack of Documentation: Failure to provide detailed records supporting the necessity of separate billing for newborn services.
3. Payer-Specific Guidelines: Misalignment with payer-specific bundling rules for maternity and newborn care.
4. Missed Eligibility Verification: Not confirming coverage details for the newborn prior to submitting claims.

Impact on Revenue Cycle Teams

OA-128 denials pose both financial and operational challenges for healthcare organizations.

Financial Impact:
- Revenue loss from denied claims requiring rework and resubmissions.
- Increased accounts receivable days, straining cash flow.
- Risk of write-offs if appeals are unsuccessful or submission deadlines are missed.
- Higher operational costs due to resources allocated for denial management.

Operational Impact:
- Staff time diverted from essential RCM activities to address denials.
- Need for specialized knowledge of payer rules and bundled billing policies.
- Coordination among billing, coding, and clinical teams to resolve denials effectively.
- Greater reliance on denial tracking and reporting to identify trends.

To combat these challenges, healthcare organizations need robust denial management strategies. CombineHealth.ai’s AI-powered tools, including Adam (AI Denial Manager), empower RCM teams to identify, track, and resolve OA-128 denials efficiently, minimizing revenue leakage and improving overall cash flow.

Steps To Appeal a OA-128 Denial

Step 1: Review the Denial Notice
Carefully examine the explanation of benefits (EOB) or remittance advice to confirm that the denial falls under OA-128.

Step 2: Gather Documentation
Collect all relevant documents, including itemized bills, clinical records, and proof of medical necessity for newborn services.

Step 3: Verify Eligibility
Confirm that the newborn is covered under the mother’s policy and check for any exceptions that may justify separate billing.

Step 4: Prepare Appeal Letter
Draft a comprehensive appeal letter, highlighting supporting documentation and referencing payer-specific policies.

Step 5: Submit Within Deadline
Ensure the appeal is submitted within the payer’s designated timeframe to avoid rejection due to late submission.

Step 6: Track and Follow Up
Monitor the appeal's status closely and follow up with the payer if necessary to expedite resolution.

How To Prevent OA-128 Denials

Preventing OA-128 denials requires a proactive approach across billing and claim submission processes.

Front-End Prevention

• Verify Coverage Details: Confirm maternity and newborn bundling policies during patient registration.
• Preemptive Documentation: Ensure clinical records clearly differentiate newborn care from the mother’s services.

Billing Best Practices

• Bundle-Aware Coding: Use accurate codes that align with payer bundling policies for maternity care.
• Claim Scrubbing: Identify issues related to newborn billing before submission with thorough claim scrubbing.

Technology Solutions

• Automated Eligibility Checks: Utilize tools like CombineHealth.ai’s platform for real-time coverage verification.
• AI-Powered Denial Management: Employ Adam for tracking and resolving denial trends effectively.

CombineHealth.ai’s advanced solutions, including Rachel (AI Appeals Manager), streamline both prevention and appeals processes. By automating eligibility verification and leveraging AI-driven insights, RCM teams can significantly reduce OA-128 denials and improve operational efficiency.

FAQs

Q1: What does OA-128 mean in medical billing?
OA-128 indicates that newborn services are bundled with the mother’s hospital allowance, and no separate payment is made for the newborn.

Q2: Can OA-128 denials be appealed?
Yes, appeals can be submitted with proper documentation and references to payer policies.

Q3: How long do I have to appeal?
Timelines vary by payer but typically range from 30 to 90 days. Check your payer’s guidelines for specific deadlines.

Q4: How can I prevent these denials?
Front-end eligibility checks, accurate coding, and leveraging technology solutions like CombineHealth.ai’s platform can minimize OA-128 denials. See our complete guide on denial prevention.