24: Charges are covered under a capitation agreement/managed care plan

Denial Occurrence:

• Capitation: Capitation is an agreement between a provider and a payer where a payer pays a fixed amount to a provider per patient for a specific period of time and it is regardless of the quantity of the services given to the patient. A patient can receive a high or less number of services.
• This denial occurs when the patient is a part of the capitation agreement.
• When this denial occurs from Medicare/Medicaid payer then it is not related to the capitation agreement and it states that the claim needs to bill to managed care insurance.
• Fee For Service: Fee for service is a plan where insurance pays each service given by the provider, so it's the insurance's responsibility to pay each claim.

On Call Scenario:

                          

                          Claim paid directly to provider under Capitation contract/Claim

                          denied as patient covered under capitation or managed care plan
                              ↙                                                                          ↘
  For Medicare/Medicaid Payer                                            For Other Payers
                         ↓                                                                                    ↓
       May I get the denial date?                                    May I get the processed and paid date?
                         ↓                                                                                    ↓
      Which managed care payer                            What is the AA, PA and Patient Responsibility?
           is active on DOS?                                              (Coins, Deductible or Copayment)
                        ↓                                                                                     ↓
 Can I get policy ID, claim mailing                             May I know whether this patient is 
address for managed care insurance?                           covered under Capitation or not?
                        ↓                                                         ↙                                              ↘
May I get the Claim# & Call ref#?                       No                                                 Yes
                                                                               ↓                                                     ↓
                                                              Could you please send              May I know the start and end
                                                          claim back for reprocessing         date of the capitation contract?
                                                            as the patient is not under                                 ↓
                                                                    the capitation?                     Check if DOS lies between
                                                                           ↙                                  capitation contract start and

                                                      What is the TAT for                                         end date

                                                           reprocessing?                                       ↙                       ↘

                                                               ↙                                                 No                              Yes

                                           May I get the Claim#                                   ↙                                    ↓

                                                 & Call ref#?                    Could you please send              May I get the

                                                                                     claim back for reprocessing         Claim# & Call
                                                                                        as the DOS does not lie                     ref#?
                                                                                    between the capitation period?

                                                                                                         ↓

                                                                                 What is the TAT for reprocessing?

                                                                                                         ↓

                                                                                         May I get the Claim#

                                                                                                 & Call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the denial receives from Medicare/Medicaid insurance and have the details of managed care insurance, policy ID, claim mailing address then you can update the managed care insurance as primary and submit the claim to that insurance.
• You can also check the Medicare/Medicare web portal if access is available to get managed care information.
• If the denial receives from Medicaid payer then managed care insurance can be billed with the same policy ID as Medicaid insurance except for BCBS payer.
• If the denial receives from Medicare payer then managed care insurance cannot be billed with same policy ID as Medicare. Need to find out the correct policy on call or their portal.
• When billing the claim to the managed care insurance as primary then do not keep Medicare/Medicaid payer as secondary payer. Medicare/Medicaid will not be responsible to pay the claim and they will keep denying the claim for denial code - 24.
• If the rep confirms that the patient is not covered under the capitation agreement and agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the rep confirms that the patient is covered under the capitation agreement and the DOS does not lie between the capitation agreement period and agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the rep confirms that the patient is covered under the capitation agreement and the DOS lies between the capitation agreement period then the claim must be written off since it is processed under the contract where a fixed amount has been decided to pay to the provider.
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