Denial Code CO 24

Denial Code CO 24 – Charges are covered under a capitation agreement or managed care plan.

When faced with Denial code CO 24, the first step is to confirm whether the claim was processed as part of a capitation agreement or if it was denied due to being covered under a managed care plan.

For claims processed under a capitation agreement, it is essential to review the terms of the agreement to ensure that the denial is not a contractual issue.

On the other hand, if the denial was due to the claim being covered under a managed care plan, it is crucial to review the plan details.

Healthcare providers need to understand the nuances of denial code CO 24 to effectively address and prevent such denials.

What is Capitation agreement and Managed care plan?

Capitation agreements and Medicare managed care plans play integral roles in the healthcare system, impacting both providers and patients. A capitation agreement is a payment model in which healthcare providers receive a fixed amount per patient for a defined period, regardless of the services provided. This arrangement shifts financial risk from payers to providers, incentivizing cost-effective care delivery.

On the other hand, Medicare managed care plans are an alternative to traditional fee-for-service Medicare, where beneficiaries enrol in private health plans that contract with Medicare to provide all Part A and Part B benefits. These plans often utilize capitation agreements with healthcare providers to control costs and improve care coordination

When a Medicare beneficiary is enrolled in a Medicare Advantage plan and healthcare providers submit claims to the Medicare insurance company instead of the Medicare managed care plan for reimbursement, it can lead to denial of claims. A common denial code in this scenario is CO 24, which indicates that claims should be submitted to the Medicare managed care plan for reimbursement.

This denial occurs because Medicare Advantage plans, also known as Medicare Part C plans, are private insurance plans approved by Medicare. They operate independently from the traditional Medicare program. Providers must bill claims directly to the Medicare Advantage plan rather than to the traditional Medicare insurance company. Failure to do so results in denials, such as the CO 24 denial code.

For example:

When a Medicare patient enrolled in a BCBS Managed care plan has their claims mistakenly submitted to original Medicare instead of the BCBS Medicare Managed care plan, the claims will likely be denied by original Medicare with denial code CO 24. In such cases, it is imperative for the provider to take corrective action by submitting those claims to the BCBS Medicare Managed care plan for reimbursement.

Submitting claims to the correct payer is crucial in ensuring timely and accurate reimbursement for services provided to patients. In this scenario, the provider should promptly identify the error, rectify it by submitting the claims to the appropriate payer, BCBS Medicare Managed care plan, and follow up to ensure that the claims are processed and reimbursed accordingly.

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

Denial Code CO-24 occurs when a claim is processed under a capitation agreement. To resolve this denial code, one must carefully review the capitation agreement terms to ensure that the services billed are covered under the agreement. Here are the steps to solve Denial Code CO-24:

• In this scenario, it is recommended to promptly contact the claims department to address any issues related to capitation agreements. It is crucial to review the terms and conditions of the capitation agreement, specifically focusing on the start and end date of the agreement. By understanding the period of the capitation agreement, stakeholders can ensure compliance and proper administration of the agreement.
• When the Date of Service (DOS) falls outside the timeframe specified in the capitation agreement, it is crucial to promptly address this discrepancy to ensure accurate reimbursement. In such instances, it is imperative to request the representative to return the claim for reprocessing.
• When the Days of Service (DOS) fall between capitation agreements, it is vital to conduct a thorough review of various financial elements. In such scenarios, it is essential to examine the allowed amount, capitation amount, and patient responsibility to determine the correct course of action. The allowed amount represents the maximum payable under the terms of the contract, while the capitation amount signifies the fixed fee paid for a specific period, regardless of service provision. By comparing these figures with the patient responsibility, which denotes the amount the patient is expected to pay out-of-pocket. After examining healthcare providers can adjust the capitation amount.

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

To solve Denial Code CO 24, which indicates that the claim was denied because the services are covered under a Medicare Managed care plan, follow these steps:

• When facing a denial from Medicare, the initial step is to ascertain the eligibility of your Medicare insurance to determine the specific Medicare Managed Care Plan in place at the time of service. If you are unable to check Medicare eligibility, it is essential to contact the Medicare claims department directly to verify the individual’s eligibility status.
• The next step in obtaining details such as Policy#, claim address, or contact number for a Medicare managed care plan insurance is to check the application. If this information is not available in the application, it is recommended to contact the Medicare managed care plan insurance department directly to acquire the necessary details.
• Finally submitting claims to Medicare managed care plan insurance companies for reimbursement involves several key steps to ensure eligibility and accuracy. First, it is important to verify the patient’s eligibility by confirming their enrolment in the Medicare managed care plan and ensuring that the services provided are covered under their plan.

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