OA-135 Denials Explained: How to Identify, Appeal, and Prevent Them

Interim billing denials, such as OA-135, are a common yet avoidable challenge for revenue cycle management (RCM) teams. These denials arise when claims are submitted before the patient is discharged, creating unnecessary delays in reimbursement and impacting cash flow. Understanding OA-135 denials, their causes, and how to effectively address them is critical for RCM teams aiming to optimize operations and maximize revenue.

In this blog, we’ll break down the OA-135 denial code, explore its financial and operational impact, and provide actionable strategies to appeal and prevent these denials.

What Is a OA-135 Denial?

The OA-135 denial code is issued when interim bills—claims submitted before a patient’s discharge—are rejected by the payer. The payer requires a final claim to be submitted post-discharge to ensure accurate billing for all services provided during the patient’s stay.

The "OA" prefix stands for "Other Adjustment," indicating that the denial is neither the patient's responsibility (PR) nor a contractual obligation (CO). In the case of OA-135, financial responsibility lies with the provider, as the denied claim must be corrected and resubmitted.

Comparison: OA-135 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
OA-135	Other Adjustment	Interim bills cannot be processed.	Provider
CO-45	Contractual Obligation	Charges exceed payer’s allowable fee.	Provider/Payer
PR-96	Patient Responsibility	Non-covered service.	Patient

While OA-135 denials stem from premature claim submissions, CO-45 focuses on contractual payment limits, and PR-96 involves services not covered under the patient’s plan. OA-135 places the burden entirely on the provider for correction and resubmission.

Common Causes of OA-135 Denials

1. Premature Claim Submission: Claims sent before the patient’s discharge result in interim billing rejections.
2. Miscommunication Between Departments: Lack of coordination between clinical and billing teams can lead to incorrect timing for claim submission.
3. Incomplete Patient Records: Missing discharge documentation prevents the payer from processing the final claim.
4. Lack of Payer Knowledge: Failure to understand payer-specific billing requirements contributes to interim billing errors.

Impact on Revenue Cycle Teams

OA-135 denials have far-reaching consequences for healthcare organizations, affecting both financial performance and operational efficiency.

Financial Impact:
- Delayed reimbursements extend accounts receivable days, disrupting cash flow.
- Increased risk of write-offs if denial appeals are not submitted within the payer’s deadline.
- Additional costs associated with staff time spent on denial rework.

Operational Impact:
- Diverted staff resources reduce efficiency in other RCM functions.
- Teams require in-depth knowledge of payer-specific rules for accurate claim submission.
- Denial trends must be tracked to identify root causes and implement corrective measures.

To combat these challenges, healthcare organizations can leverage CombineHealth.ai's Adam (AI Denial Manager), which automates denial tracking and resolution, reducing the administrative burden and improving cash flow.

Steps To Appeal a OA-135 Denial

Step 1: Review the Denial Notice
Carefully examine the explanation of benefits (EOB) or electronic remittance advice (ERA) to confirm the reason for the denial.

Step 2: Gather Documentation
Compile necessary records, including discharge summaries and finalized patient charts, to support your appeal.

Step 3: Verify Eligibility
Confirm the claim meets payer policies for final billing after discharge.

Step 4: Prepare Appeal Letter
Include patient details, claim information, and supporting documentation. Explain the corrective actions taken to resolve the issue.

Step 5: Submit Within Deadline
Ensure the appeal is submitted within the payer’s specified timeframe to avoid forfeiting reimbursement.

Step 6: Track and Follow Up
Monitor the progress of the appeal and follow up with the payer if needed. Use denial tracking tools like Adam to streamline this process.

How To Prevent OA-135 Denials

Proactive measures can significantly reduce the occurrence of OA-135 denials. Here’s how:

Front-End Prevention

• Implement Discharge Coordination Protocols: Ensure billing teams receive discharge notifications promptly to prevent premature submissions.
• Train Staff on Payer Requirements: Educate RCM teams about payer-specific interim billing policies.

Billing Best Practices

• Submit Claims Post-Discharge: Verify discharge documentation before sending claims to payers.
• Conduct Pre-Submission Audits: Review claims for completeness and accuracy prior to submission.

Technology Solutions

• Leverage Claim Scrubbing Software: Use CombineHealth.ai’s automated claim scrubbing tools to identify billing errors related to discharge timing.
• Adopt AI for Denial Prevention: Deploy Rachel (AI Appeals Manager) to assist in identifying and resolving potential denial triggers.

CombineHealth.ai’s intelligent platform streamlines claim submission processes, reducing the likelihood of OA-135 denials and enabling efficient appeals when necessary.

FAQs

Q1: What does OA-135 mean in medical billing?
OA-135 indicates that interim bills submitted prior to patient discharge cannot be processed. The provider must resubmit a final claim post-discharge.

Q2: Can OA-135 denials be appealed?
Yes, providers can appeal OA-135 denials by submitting corrected claims and supporting documentation within the payer’s deadline.

Q3: How long do I have to appeal?
Appeal timelines vary by payer but are typically stated in the denial notice. Providers should act promptly to avoid missed deadlines.

Q4: How can I prevent these denials?
Prevent OA-135 denials by implementing discharge coordination protocols, conducting pre-submission audits, and utilizing denial management tools like Adam. See our complete guide on denial prevention.