CARC 24
Covered under a capitation or managed care arrangement
The payer considers this service already paid for under a capitation agreement or managed care plan.
Why you actually get this
- The patient is enrolled in a managed care plan the practice did not identify at registration.
- The service falls inside a capitated arrangement and is not separately billable.
- Eligibility was verified against the wrong plan.
How to check whether it’s correct
- 01Re-verify which plan the patient was enrolled in on the date of service, not today.
- 02Confirm whether the service is inside or outside the capitated scope.
Sometimes worth appealing
Worth working where the service genuinely sits outside the capitated scope, or where the patient was not enrolled on the date of service. Not worth appealing where the arrangement plainly covers it.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.