Last Modified: 5/16/2020
Location: FL, PR, USVI
Business: Part B
Q: We received a RUC for claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?
Charges are covered under a capitation agreement/managed care plan.
A: This reason code is received when a claim is submitted to Medicare, and the beneficiary is enrolled in a Medicare Advantage (MA) plan, or is covered under a capitation agreement.
Medicare Advantage (MA):
• If a Medicare beneficiary enrolls in an MA plan, the MA plan replaces the beneficiary’s traditional Medicare plan.
• Medicare claims must be submitted to the MA plan.
• If a claim is submitted to Medicare, it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate CARC CO24.
• Obtain eligibility and benefit information prior to rendering services.
• Ask your patient if he/she has recently enrolled in any new health insurance plans.
• Request to see a copy of all of the patient’s health insurance cards.
• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.
• Click here
for ways to verify beneficiary eligibility prior to submitting claims to First Coast.
Review Eligibility and Benefits tutorial
to see how to verify eligibility and access corresponding benefits information on one of the most popular features of the Secure Provider Online Tool (SPOT).
• If the beneficiary's record with CMS is updated to reflect that he/she was not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).
• Claims that are returned as unprocessable cannot be appealed. , for more information.
End-stage renal disease (ESRD) capitation agreement:
• Prior to seeing a patient for ESRD-related dialysis, verify eligibility. If the patient is covered under a capitation agreement, contact the capitation provider before rendering the service.
ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines
correct the claim, including the use of appropriate modifiers, and resubmit the corrected claim for payment.
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