How do I fix or resolve code 136?

Obtain the primary payer's EOB/ERA and the accompanying RARC to identify which specific coverage rule was not followed (e.g., missing referral, missing authorization, out-of-network service). Verify whether the required referral, authorization, or network restriction was actually in place for the date of service by checking the primary payer's portal or contacting the primary payer directly. If the coverage rule was followed but the primary payer incorrectly denied the claim, file an appeal with the primary payer to overturn the denial; once the primary pays, resubmit to the secondary with the corrected primary EOB. If the coverage rule was genuinely not followed, determine whether the primary payer allows retro-active referrals or authorizations and request one if possible. If the primary payer will not overturn the denial and the secondary payer denies based on the primary's rules, bill the patient or write off the balance as a provider adjustment depending on the plan provisions.

136Denial CodeGeneral Adjustment

Code 136

Problem Description

Failure to follow prior payer's coverage rules. (Use only with Group Code OA)

Root Cause

The claim was denied because the provider failed to follow the prior payer's coverage rules. This is used exclusively with Group Code OA (Other Adjustment) and occurs in coordination of benefits scenarios where the primary payer had specific coverage rules — such as a required referral, prior authorization, or network restriction — that were not followed. The secondary payer denies the claim because the primary payer's rules were not adhered to, making the service non-covered under the primary plan. The secondary payer is not responsible for a service that the primary payer would have covered had its rules been followed.

Resolution Steps

1Obtain the primary payer's EOB/ERA and the accompanying RARC to identify which specific coverage rule was not followed (e.g., missing referral, missing authorization, out-of-network service).
2Verify whether the required referral, authorization, or network restriction was actually in place for the date of service by checking the primary payer's portal or contacting the primary payer directly.
3If the coverage rule was followed but the primary payer incorrectly denied the claim, file an appeal with the primary payer to overturn the denial; once the primary pays, resubmit to the secondary with the corrected primary EOB.
4If the coverage rule was genuinely not followed, determine whether the primary payer allows retro-active referrals or authorizations and request one if possible.
5If the primary payer will not overturn the denial and the secondary payer denies based on the primary's rules, bill the patient or write off the balance as a provider adjustment depending on the plan provisions.

EHR Documentation Note

Claim denied 136 — failure to follow prior payer coverage rules (OA); identified unmet primary requirement, appealed with primary payer, or requested retro-referral/authorization.

Preventative Action

Verify primary payer coverage rules (referrals, authorizations, network status) before rendering services and track primary payer requirements in the practice management system for COB patients.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.