CO24 denial code description and corrective action

• Capitation is an agreement between a provider and a payer in which the payer pays a fixed amount to the provider per patient for a specific period of time, regardless of the number or cost of services the patient receives. This means a patient may receive many services or very few, but the payment to the provider remains the same.

• This denial occurs when the patient is covered under a capitation agreement, or when payment has already been made to the provider under the per-capitation arrangement.

• There is a list called the capitation list, which shows the names of patients covered under the capitation agreement.

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer.

• The most important step is to determine whether the claim denial is valid or if the insurance has denied the claim by mistake.

• Call the insurance company and discuss the denial with the representative. If the DOS falls outside of the capitation period or if the patient is not found on the capitation list, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.

• If the patient is found on the capitation list and the DOS also falls within the capitation agreement period, then write off the claim since it is already paid under capitation.

• If this denial is received from Medicare or Medicaid, then it is not related to capitation. Instead, it indicates that the claim is associated with a managed care plan.

• In this case, review the patient’s history and documents, call the insurance, check the portal, or contact the member to obtain the managed care insurance information.

• After finding the information, bill the claim to the managed care plan as the primary insurance. Do not keep Medicare or Medicaid as secondary, as they will not pay this claim and will again deny it with the same denial reason if billed as secondary.

• In the case of Medicaid, we can bill the claim to the managed care plan using the Medicaid ID, except for BCBS-managed plans.

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