CO-24 denial code: covered under a capitation agreement or managed care plan

Claim adjustment reason code 24 says: charges are covered under a capitation agreement or managed care plan. The payer you billed isn't paying because this patient's care is paid another way: through a managed care plan, or through a fixed monthly payment to a provider.

With group code CO, the patient can't be billed. The fix is to bill the right plan, or to report the visit the way your capitation contract requires.

• The patient is in a Medicare Advantage plan and the claim went to Original Medicare. Medicare often uses CO-24 for this. A patient who joined a Medicare Advantage plan still carries a red, white and blue Medicare card, which is how the wrong claim gets sent.
• The patient is in a Medicaid managed care plan and the claim went to the state's fee-for-service program.
• Your practice is paid by capitation for this patient. Under a capitated contract, covered services are already paid through the monthly amount, and the plan expects an encounter record rather than a bill.
• The plan changed during the year and the record still shows the old one.

1. Re-verify coverage for the date of service, and look specifically for Medicare Advantage or Medicaid managed care enrollment.
2. If the patient is in a managed care plan, bill that plan as a new claim, within its timely filing limit. Check that you are in its network and that any referral or approval it requires was in place.
3. If your practice is capitated for this patient, submit the visit as your contract specifies, usually as an encounter.
4. Update the patient's record with the right plan and member number.

• Check the plan type on the date of service, not just whether coverage is active.
• Re-check at the start of each year, when patients move between Original Medicare and Medicare Advantage.
• Know which patients your practice is capitated for, so their visits are reported the right way from the start.

CO-24 is decided by the patient's plan type, so it is prevented at booking.

Claira Health's AI agents confirm coverage and the right payer before the visit, so this denial is stopped at the front desk instead of coming back weeks later. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

Wondering how many Medicare Advantage patients are billed as Original Medicare? Book a 20-minute call.