CARC 24 Active

OA-24: Charges Covered Under Capitation/Managed Care

TL;DR

Adjustment in a COB or secondary payer context. Review the coordination of benefits details to determine the responsible party.

Action
Review & Decide
Who Pays
Depends
Appeal
Yes
Patient Impact
Indirect
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does OA-24 Mean?

With OA (Other Adjustments), CARC 24 typically appears in a coordination of benefits (COB) context. Capitation adjustment applied in coordination with other payers. The financial responsibility depends on the specific arrangement between payers — review the primary payer's EOB and the COB terms to determine the correct course of action.

CARC 24 means the payer adjusted the payment based on charges covered under capitation/managed care. The reimbursement was calculated using the payer's fee schedule, contracted rate, or regulatory payment methodology rather than the billed charge.

Common scenarios that trigger this adjustment include: the service billed is already covered under the provider's capitation agreement with the managed care plan; Provider submitted a fee-for-service claim for a service that should be paid through the capitation arrangement; Claim was submitted to the wrong plan within a managed care organization. The group code paired with CARC 24 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, OA indicates a coordination of benefits or other payer adjustment, PR shifts it to the patient.

Common Causes

Cause Frequency
Capitation arrangement in COB context Capitation adjustment applied in coordination with other payers Most Common

How to Resolve

  1. Review the coordination of benefits Examine the OA-24 adjustment to understand how it fits within the primary/secondary payer relationship or other multi-payer context.
  2. Verify primary payer adjudication Review the primary payer's EOB to understand the basis for the secondary payer's OA adjustment.
  3. Determine the responsible party Based on the COB review, identify whether the adjustment should be absorbed, billed to another payer, or if additional documentation is needed.
  4. Appeal or resubmit if needed Appeal with capitation contract documentation showing the service is not included.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Appeal Guide

Appeal with capitation contract documentation showing the service is not included.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-24:

RARC Description
N381 Consult contract/fee schedule for payment information Review capitation terms →

How to Prevent OA-24

Also Filed As

The same CARC 24 may appear with different Group Codes:

CO-24 PR-24

Related Denial Codes

OA-45 — Charge Exceeds Fee Schedule/Maximum Allowable OA-271 — Prior Contractual Reductions on Current Payment Schedule OA-308 — Contracted Funding Agreement Adjustment OA-1 — Deductible Amount OA-2 — Coinsurance Amount

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.