CARC 274 Active

PR-274: Fee/Service Not Payable — Care Coordination Arrangement

TL;DR

The service is not payable under the patient's care coordination arrangement (such as an ACO or bundled payment plan). Review the arrangement terms, verify coding, and appeal if the service should be separately billable outside the arrangement.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
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 PR-274 Mean?

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.

How to Resolve

Review the care coordination arrangement, verify coding, and resubmit or appeal if the service should be separately payable.

  1. Review the care coordination agreement Understand which services are covered, excluded, and subject to limits under the patient's care coordination arrangement.
  2. Verify service coverage Check whether the billed service falls within the arrangement's covered services by comparing procedure codes against the agreement terms.
  3. Contact the payer for clarification Reach out to the care coordination team or payer to understand why the service was denied and what documentation might change the determination.
  4. Correct coding errors and resubmit If the denial resulted from a coding error, correct the codes and resubmit the claim.
  5. Appeal if warranted If the service should be covered under the arrangement, file a formal appeal with supporting documentation including the care coordination agreement terms and clinical records.
Do Not Appeal This Code

Fee/Service Not Payable — Care Coordination Arrangement grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

Also Filed As

The same CARC 274 may appear with different Group Codes:

CO-274 OA-274

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

Sources

  1. https://www.mdclarity.com/denial-code/274
  2. https://x12.org/codes/claim-adjustment-reason-codes
  3. Codes maintained by X12. Visit x12.org for official definitions.