CO-24: Charges are covered under a capitation agreement/managed care plan.

Why it fires

• The patient is enrolled in a capitated plan where the PCP or IPA is paid a flat per-member fee that is meant to cover this service
• The provider is contracted under a capitation arrangement for this service category
• The service should have been billed to the capitated entity, such as an IPA or medical group, rather than the health plan directly

Corrective actions, ranked

1. 1

   Confirm the capitation arrangement

   Verify whether this specific service is genuinely included in the provider's or the patient's capitation agreement.

2. 2

   Bill the correct capitated entity

   If a different entity, such as an IPA or medical group, holds the capitation risk for this service, submit the claim or encounter data to them instead.

3. 3

   Submit as encounter data

   Many capitated services still require encounter or informational reporting to the health plan even though no separate payment is made.

Is it worth appealing

Rarely appealable to the health plan directly. If payment is owed, it typically must be pursued through the capitated entity, not a formal payer appeal.

Other denial codes to check

Codes that share a remark code with this one, or that are reported under the same group code.

• CO-45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
• CO-97The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
• CO-16Claim/service lacks information or has submission/billing error(s).
• CO-11The diagnosis is inconsistent with the procedure.
• OA-18Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)
• CO-29The time limit for filing has expired.

See every CARC in the dataset