Wiki Medicare Claim Denial

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codernickie

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I received a claim denial for a medicare patient. The reason for the denial is CO-24 " charges are covered under a capitation agreement/managed care plan. Does anyone know what this mean and what I need to do on my end for the claim to be processed. I tried looking on medicare website for the meaning of this code and I could not find anything.

Any suggestions would be great

Thank You
Nickie
 
It sounds like you may have billed traditional Medicare. Patient may be covered under a Medicare HMO type plan. If you are able to view a copy of the patient's card to verify eligibility.
 
You should contact your Medicare carrier for your region, using the voice response system request eligibility, then use the date of service of your claim and Medicare should have the information as to whom is the primary insurer. Good Luck !
 
Patient is enrolled in an HMO plan, the eligibility should show you which health plan is the administrator. You can contact the health plan to obtain the member ID and the assigned IPA/Medical Group if needed.
 
if you have access to webdenis, you can confirm the MCR ADV/HMO payer on this site as well. Click on the Medicare eligibility link and enter in the required patient information. It will then tell you who the MCR ADV/HMO carrier is. this info is also available on C-Snap, a Medicare specific site. It is www.medicare.com- you also need to register for access to this site.
Hope this helps!
 
So we have a patient that had Medicare HMO at the time of service. Of course my office failed to properly check eligibility. Now I got a denial, because is an HMO and we do not contract with the medical group assigned.

Can we charge the patient?

Or basically is a lost claim?

Please advise.

Thanks.
 
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