CO-274: Fee/Service Not Payable — Care Coordination Arrangement
CO-274 means the service is not separately payable under the care coordination arrangement. Review the agreement, verify coding, and appeal if the service qualifies for separate payment.
What Does CO-274 Mean?
When paired with Group Code CO, the care coordination adjustment is contractual. The provider agreed to the arrangement terms and cannot transfer the denied amount to the patient. Review the arrangement to confirm the denial is correct, or appeal if the service should be separately payable.
CARC 274 indicates the payer denied or adjusted the claim because the billed service is not separately payable under the patient's care coordination arrangement. Care coordination arrangements include Accountable Care Organizations (ACOs), bundled payment programs, patient-centered medical homes, and other value-based care models that consolidate payment for multiple services.
Under these arrangements, some services are included in a global or bundled payment rather than being reimbursed individually. CARC 274 appears when the payer determines the billed service falls within the scope of the care coordination agreement and should not be billed separately.
The denial may also result from missing pre-authorization under the arrangement, exceeded frequency or quantity limits, the service not meeting the arrangement's medical necessity criteria, or coding errors that caused the claim to fall outside the arrangement's covered services when the service itself may be eligible.
Common Causes
| Cause | Frequency |
|---|---|
| Service not covered under care coordination agreement The billed service falls outside the coverage parameters established by the patient's care coordination arrangement, such as services excluded from a bundled care plan or ACO arrangement | Most Common |
| Missing or expired pre-authorization under the arrangement The care coordination plan requires advance approval for certain services, but the provider did not obtain authorization or the authorization expired before the service date | Common |
| Service exceeds frequency or quantity limits The care coordination arrangement limits the number of times a service can be provided within a specified timeframe, and the billed service exceeds that limit | Common |
| Service deemed not medically necessary per arrangement guidelines The care coordination arrangement has its own medical necessity criteria, and the service did not meet those standards | Common |
| Coding errors on the claim Incorrect procedure or diagnosis codes caused the claim to fall outside the care coordination arrangement's covered services when the service itself may be covered | Occasional |
How to Resolve
- Review the care coordination agreement Check which services are covered, excluded, or bundled under the arrangement.
- Verify procedure codes against agreement Compare the billed codes to the arrangement's covered services list.
- Contact the payer Clarify why the service was denied and what documentation would support coverage.
- Correct and resubmit if coding error Fix any coding issues and resubmit the claim.
- File a formal appeal Submit an appeal with the arrangement agreement, clinical documentation, and evidence the service meets coverage criteria.
File an appeal if you believe the service is covered under the care coordination arrangement. Include the arrangement agreement, clinical documentation supporting medical necessity, and evidence that the service meets the arrangement's coverage criteria. Appeal within the payer's specified timeframe.
How to Prevent CO-274
- Verify patient eligibility and care coordination arrangement coverage before providing services
- Obtain prior authorization for services that require advance approval under the arrangement
- Maintain thorough documentation of all care coordination activities and covered services
- Train staff on the specific requirements and limitations of care coordination arrangements
- Monitor claim patterns to identify recurring denials and address root causes proactively
- Stay informed about changes to care coordination agreement terms and policies
General Prevention
- Obtain prior authorization for services that require advance approval under the care coordination arrangement
Also Filed As
The same CARC 274 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/274
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.