PR-24: Charges Covered Under Capitation/Managed Care

What Does PR-24 Mean?

With PR (Patient Responsibility), the CARC 24 adjustment for charges covered under capitation/managed care shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

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.

How to Resolve

1. Review the adjustment Examine the PR-24 adjustment and any RARC codes to understand the basis for the patient responsibility.
2. Verify the adjustment is correct Confirm the PR designation and amount are appropriate based on the patient's plan benefits.
3. Appeal if incorrect If the adjustment appears incorrect, file an appeal with supporting documentation.
4. Collect from the patient if valid If the adjustment is confirmed correct, generate a patient statement and follow standard collection procedures.

How to Prevent PR-24

• Verify patient benefits and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively

Also Filed As

The same CARC 24 may appear with different Group Codes:

Related Denial Codes