100: Payment made to patient/insured/responsible party.
The insurance payment for this claim was sent directly to the patient or subscriber rather than to your practice or facility, typically because the provider is out of network or no assignment of benefits was on file.
What the group code means
- OA
- Other Adjustment. Used when neither CO nor PR applies.
Why it fires
- The provider is out of network and the plan pays out-of-network claims directly to the member
- No valid assignment of benefits form was on file authorizing payment to the provider
- The patient submitted the claim themselves rather than the provider submitting it directly
Corrective actions, ranked
- 1
Check assignment of benefits status
Confirm whether a signed assignment of benefits is on file with this payer for this patient and provider combination.
- 2
Collect from the patient
Since the payer has already paid the patient, bill the patient directly for the amount owed rather than expecting a second payment from the payer.
- 3
Get an assignment of benefits on file going forward
For future claims, ensure a current assignment of benefits form is submitted so payments come directly to the practice.
Is it worth appealing
Not appealable to the payer since payment was already issued correctly per plan terms. Pursue collection from the patient instead.
Retrieved 2026-07-18.
Do not let this happen again
Scrub the claim against NCCI PTP and MUE edits before you submit, free and in your browser.
DenialPath provides billing and administrative guidance based on published CMS and X12 sources. It is not medical advice, not a coverage determination, and not a guarantee of payment. NCCI and MUE edits are republished quarterly and payer policies vary by contract. Always confirm against the payer's own current policy before submitting or appealing.