OA 292 denial code
Claim adjustment reason code 292. Often reported as OA 292 or CO 292.
Medical plan forwarded to pharmacy plan
Unofficial reference. This is our own plain-English explanation, not the official code text. Payer rules differ. Verify with the payer and the official X12 code list. AlphaPrefix is not affiliated with X12, CMS or any payer. Data last updated .
What 292 means
The medical plan found the service is a pharmacy benefit and forwarded the claim to the patient's pharmacy plan.
The medical payer did not cover the drug or supply and passed the claim to the pharmacy benefit for you. Code 280 is the version where you are told to submit to the pharmacy plan yourself.
Pharmacy benefit claims follow different pricing and authorization rules, so the outcome may differ from medical billing.
Group codes seen with 292
On a remittance, 292 comes after a group code. These are the ones it is most often reported with:
- OA 292 (Other Adjustment): Used for adjustments that are neither the provider's contractual write-off nor the patient's share. It often appears with coordination of benefits, for example when another payer already paid.
- CO 292 (Contractual Obligation): The provider's side of the ledger. The reduction comes from the payer contract or a rule the provider has to follow, and the patient normally cannot be billed for it.
The payer chooses the group code for each adjustment, so the same reason code can appear with another group code on your remittance. Read the two together. More about group codes.
Common causes
- A drug covered under the pharmacy benefit was billed on a medical claim.
- The payer routes certain drugs or supplies to its pharmacy benefit manager.
- The plan's medical benefit excludes the item.
What to do next
- Note that the claim was forwarded and to which pharmacy plan.
- Follow up with the pharmacy benefit for the outcome if no response arrives.
- Check whether the drug needs prior authorization under the pharmacy benefit.
Related codes
- 280 (reason code) Medical plan: bill the pharmacy plan
- 291 (reason code) Medical plan forwarded to dental plan
Source
Official wording: X12 Claim Adjustment Reason Codes list. The explanation on this page is our own plain-English wording, not the X12 text.
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