CO-24: Charges fall under a capitation payment

The payer is telling you that your organization is already being paid a flat capitation amount for this member and date span. The visit or service you billed is included in that capitation package, so they will not pay an additional fee for the codes on the claim line. Mechanically, the system sees your NPI or TIN and the member tied to a capitated contract for behavioral health. When that match hits, the claim line prices to zero and CO-24 is applied to the adjustment, making the balance provider write off except for any correctly assigned patient cost share.

In behavioral health, CO-24 shows up often with Medicaid managed care and carve out BH plans that pay you per member per month. Example: your PHP or IOP clinic has a capitation deal with a Medicaid MCO for all outpatient BH visits, so a 90837 or 90853 claim comes back with CO-24 and no extra payment. The revenue is in the capitation check, not in the claim. Residential and detox facilities sometimes get partial capitation for lower levels of care such as step down IOP or outpatient therapy after discharge. If your system keeps billing fee for service 0915, 90832, or 90853 on top of that, those lines will deny with CO-24. Telehealth codes with modifier 95 or 93 can also hit CO-24 when the contract says "all outpatient BH" is capitated, including virtual. You also see CO-24 when the behavioral benefit is carved out to a different vendor that capitates care to a local CMHC or OTP. Example: the medical MCO is not capitating you, but the BH vendor is capitating a different clinic as the member's assigned behavioral home, and your claims hit CO-24 because you are not the capitated provider for that member.

• Confirm the member's eligibility and behavioral health plan for the dates of service, including any BH carve out vendor.
• Check your contract and payer portal to see if your tax ID or NPI is under a capitation agreement for that member and date span.
• If you are capitated and the services really are included, adjust off the CO-24 amount as contractual and confirm that capitation payments are posting correctly in your GL.
• If you are not capitated or the member is assigned to you as the behavioral provider, contact the payer or vendor to correct the capitation setup and request reprocessing.
• If the claim was sent to the wrong payer or to the medical plan instead of the BH carve out, void the claim if needed and submit a clean claim to the correct payer.
• If the payer refuses to correct an incorrect CO-24, file an appeal with eligibility proof and contract references showing you are owed fee for service payment.

• At intake, verify not only medical coverage but also the behavioral health plan, assigned BH home, and any capitation notes.
• Configure your practice management system to flag or suppress fee for service claims for members and lines that are under capitation for that payer.
• Maintain a clear crosswalk of which levels of care and CPT or HCPCS codes are capitated versus billable so clinicians and schedulers know what can be billed.
• Audit capitation contracts quarterly to confirm your payer selections, billing rules, and revenue posting match how the payer is adjudicating claims.