RemitBench/Denial codes/CO-24

CO-24 denial code

Code 24 says this care is paid for under an arrangement rather than per claim. Somebody receives a fixed amount to look after this patient, and that arrangement covers what you did.

The code list's own wording: Charges are covered under a capitation agreement/managed care plan.

What it means: The patient is assigned to a provider or group that receives a fixed payment to cover their care. Claims for services inside that arrangement are not paid separately, because the money already went out.
Who owes the money: The capitated provider Not the patient. If you are the capitated provider, you have already been paid. If you are not, the arrangement holder is who you deal with, not the patient.
Is appealing worth it: Rarely. The useful questions are whether the patient is correctly assigned, and whether the service falls inside the capitated scope. Both are factual.

Work out which side of the arrangement you are on. If your practice holds the capitation, the money arrived as a monthly payment and there is nothing to collect. If you do not, the patient was assigned elsewhere and either the assignment is wrong or you treated someone else's capitated patient. Those are completely different problems and the code does not tell you which one you have.

Why the payer sent it

The patient is assigned to a capitated provider or group and you are it.
The patient is assigned elsewhere and should have been seen there.
The assignment is out of date and the patient has changed providers.
The service is inside the capitated scope when you expected it to be outside.
A referral was required and was not obtained, which is closer to CO-288.

Remark codes you will see with it

Remark code	What it adds
N130	Read the plan document for what the arrangement covers. Its own page.
N30	The patient was ineligible for this service. See N30.

Remark code

What it adds

N130

Read the plan document for what the arrangement covers. Its own page.

N30

The patient was ineligible for this service. See N30.

Read the letters in front of the 24

CO-24: Contractual obligation. The normal pairing. Correct if you hold the capitation.
OA-24: Other adjustment. Neither side owes it.
PI-24: Payer initiated. Not the patient's money.
PR-24: Patient responsibility. Hard to justify. A patient assigned to a capitated provider is not usually the one who owes for the confusion.

What to do next

Find out who the patient is assigned to

One question to the payer. It splits the problem cleanly and everything else follows from the answer.
If it is you: nothing to collect. Post it and check your capitation payments cover the volume you are seeing. If it is somebody else: either the assignment is wrong, or the patient should be seen there. Both need the patient in the conversation.
Check whether the service is inside the capitated scope

Most arrangements cover a defined list. Services outside it are usually billable separately, and that boundary is where the recoverable claims are.
If the assignment is stale, get it corrected

Patients change providers and the record lags. A corrected assignment often makes the claim payable, and it prevents the next one.

Codes that get mixed up with 24

Code	How it differs from 24
109	Not covered by this payer. Wrong payer rather than a different payment arrangement. See CO-109.
242	Services not provided by network providers. A network problem rather than a capitation one. See CO-242.
B9	The patient is enrolled in hospice. Another case of care paid outside the normal claim route. See CO-B9.
22	Another payer may be primary. See CO-22.

Code

How it differs from 24

109

Not covered by this payer. Wrong payer rather than a different payment arrangement. See CO-109.

242

Services not provided by network providers. A network problem rather than a capitation one. See CO-242.

The patient is enrolled in hospice. Another case of care paid outside the normal claim route. See CO-B9.

Another payer may be primary. See CO-22.

Code 24 in dental

Dental HMO plans are built on exactly this arrangement. The patient is assigned to an office that receives a monthly amount per member, and claims for covered services inside that arrangement are not paid per claim.

Check the assignment before the appointment, not after

On these plans a patient can only be treated at the office they are assigned to, and switching takes effect from a future date rather than immediately. A practice that verifies assignment at booking avoids treating a patient whose care it will never be paid for.

The patient schedule is where your money is

Under a dental capitation arrangement the patient pays a set amount for many procedures, and that schedule is a real part of the practice income. A 24 on a claim is normal on these plans and is not a sign anything went wrong.

Questions people ask about CO-24

Can I bill the patient for a CO-24?

Not for services inside the capitated arrangement. The plan has already paid for that care through a fixed periodic payment to the assigned provider. Where the service falls outside the arrangement's scope, normal billing rules apply and the patient's share follows the plan's schedule.

What if the patient is assigned to a different office?

Then either the assignment record is out of date, or the patient was seen somewhere they are not covered to be seen. Ask the payer who the patient is assigned to, and involve the patient, because changing an assignment is something only they can start.

Related codes

Back to all denial codes

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