Denial Code CO 24

When we received the Denial code co 24, first we need to check whether claim processed towards capitation agreement, or it is denied as the claim covered under managed care plan.

So, let us learn about capitation agreement and Medicare managed care plan to better understand the above denial.

What is Capitation Agreement?

It’s an agreement between medical provider and insurance company, that a fixed payment insurances paid per patient to medical provider for the specific period of time, irrespective of number of visits for the health care services which is included in the contract. The payment is not affected by the type or number of services provided.

What is Medicare Managed Care plan?

Medicare Managed Care plan is also called as Medicare advantage plan or Medicare part C. Medicare Managed care plans are offered by private commercial insurance companies, which follows Medicare guidelines to cover additional services that original Medicare doesn’t. Many Medicare Managed care plan covers the following coverages – drug, dental, vision care or wellness programs.

Denial Code CO 24 is one of the most common and frequent denial which we come across in Medicare insurance denial bucket.

When the Medicare beneficiary is enrolled with Medicare advantage plan, but provider submit those claims to Medicare insurance company instead of submitting it to Medicare managed care plan for reimbursement. Then those claims will be denied by Medicare insurance company with denial code CO 24, indicating claims should be submitted to Medicare managed care plan for reimbursing the claim.

For example:

Consider Medicare patient is enrolled with BCBS Managed care plan, but provider submitted the claims to original Medicare instead of submitting to BCBS Medicare Managed care plan. Then those claims will be denied by original Medicare with denial code CO 24.

Here provider should submit those claims Medicare Managed care plan BCBS for reimbursing the claims.

How to solve Denial Code CO 24 – when claim processed towards Capitation agreement?

• In this scenario we should reach out the claims department and then check period of capitation agreement (start and end date).
• If the DOS does not lie between capitation agreement date, then we need to request the representative to send the claim back for reprocessing.
• If the DOS lies between capitation agreement, then we need to check the allowed amount, capitation amount and the patient responsibility. Need to adjust the capitation amount.

How to solve Denial Code CO 24 – when claim denied as services covered under Medicare Managed care plan?

• Whenever you receive this denial from Medicare, the very first step is to check eligibility of Medicare insurance to get the Medicare Managed care plan insurance name at the time of service. If unable to check the Medicare eligibility, then reach out Medicare claims department to verify the same.
• Next step is to see the application to get the details (like Policy#, claim address or contact number) of Medicare managed care plan insurance if available, if not reach out the Medicare managed care plan insurance department to avail the same.
• Finally check the eligibility, add, and submit the claims to Medicare managed care plan insurance company for reimbursement.

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)