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?
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:
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.
- Click here to go to Quiz
Thank you, As this scenario is really helpful.Earlier I used to be confused of what questions needs to be asked from insurance rep
ReplyDeleteThank you for the response...
DeleteSo tell me what is Capitation!
DeleteCapitation is A payment method for health care services. The physician, hospital, or other health care
Deleteprovider is paid a contracted rate for each member assigned, referred to as "per-member-per-month" rate, regardless of the number or nature of services provided. The contractual rates are usually adjusted for age, gender, illness, and regional differences.
Im confused with this denial. So, it means that if the patient has Medicaid but a replacement for example Steward, the one that needs to be bill will be Steward and no Medicaid? Am I correct?
ReplyDeleteYes, you are correct. If claim will be billed to Medicaid then Medicaid will deny it stating claim needs to be billed to managed care/replacement plan. So, correct payer is Steward that needs to be billed.
Deletewhat will happen to the balance amount after the capitation adjustment, the remaining balance will it go to pt. or it will be adjusted?
ReplyDeleteIf the DOS lies within capitation period then the total amount will be written off.
DeleteNo we cannot write off directly, we have check in portal does patient has any HMO managed care plan or not. If patient has, we need to bill to managed care plan
DeleteYes, you are correct. Just go through with the above scenario once again. it will help you to understand both the actions. When to bill managed care plan and when to write off the claim.
Deleteso if patient has straight medical, no OHC and medical denies claim... Who should be billed then?
ReplyDeleteIf the above denial is received from the payer other than Medicaid/Medicare then you can follow the above scenario tree with option 'Other Payers'.
DeleteThank
ReplyDeletehello
DeleteWhat is Denial code for capitation?
ReplyDeleteIt is 24.
DeleteThanks for helping us to understanding the exact denial reason for CO24
ReplyDelete👍
DeleteDo you have any telegram page, so that we can ask some questions directly?
ReplyDeleteYou can ask your question in the comment section of any post or you can email us at contact@arlearningonline.com or whatsapp at +91 8097279620.
DeleteIf claim denied as capitated and
Deletethe payer and let them know that we received payment for this provider,
bro your content is very helpful, thanx for providing this kind of knowledge
ReplyDeleteThank you!
DeleteJus in case if Member doesn't have any MANAGE CARE PLAN what needs to be done
ReplyDeleteIf the claim is denied by Medicare/Medicaid for 24 stating it is covered under managed care plan and when you checked the eligibility and found that there is no managed care plan on DOS then you can call the insurance and ask to reprocess the claim.
Deletethe claim denied stating 24-24 CHGS COVD UNDER CAPITATED AGREEMENT what needs to be done on this
ReplyDeletePlease follow the above scenario.
DeleteHow to prepare notes for CO 24 - Charges covered under Capitation. Can you help me by giving 1 example of notes format?
ReplyDeletewhat is 72 hour rule skilled nursing facility ? do we need to write off
ReplyDeleteThe 72-hour rule requires insurance to cover services if the patient is admitted for at least 3 consecutive days. If the criteria is not met then claim gets denied. You must confirm with your client whether such claims can be adjusted off or not. Also, if the ABN is signed by the patient then you can bill it to patient.
DeleteIn case if you have multiple lines on a claim should you ask allowed for each line item or asking a total allowed for the whole claim is fine? which one is better and why?
ReplyDeleteIt is always good to confirm the allowed and paid amount of each line item. However, sometimes the number of line items are very high, in that case getting the total allowed and paid amount would be fine if all line items are paid.
Delete