Return unprocessable claim (RUC) reason code CO24 FAQ
Q: We received a RUC for claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?
Denial – Charges are covered under a capitation agreement/managed care plan.
A: This reason code is received when a claim is submitted to Medicare, and the beneficiary is enrolled in a Medicare Advantage plan or is covered under a capitation agreement.
Medicare Advantage (MA):
- If a Medicare beneficiary enrolls in an MA plan, the MA plan replaces the beneficiary’s original Medicare plan.
- Medicare claims must be submitted to the MA plan.
- If a claim is submitted to Medicare, it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate CARC CO24.
- Obtain eligibility and benefit information prior to rendering services.
- Ask your patient if he/she has recently enrolled in any new health insurance plans.
- Request to see a copy of all of the patient’s health insurance cards.
- Always remember to check beneficiary eligibility prior to submitting claims to Medicare.
- Click here for ways to verify beneficiary eligibility prior to submitting claims to First Coast.
- Review SPOT eligibility reports FAQ to see how to verify eligibility and access corresponding benefits information on one of the most popular features of the SPOT.
- If the beneficiary’s record with CMS is updated to reflect that he/she was not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast.
- Claims that are returned as unprocessable cannot be appealed
End-stage renal disease (ESRD) capitation agreement: - Prior to seeing a patient for ESRD-related dialysis, verify eligibility. If the patient is covered under a capitation agreement, contact the capitation provider before rendering the service.
Denial – Services billed require a Bilateral Modifier per CMS guideline
If your claim was denied due to missing information: You may resubmit the claim with the updated information. The data needed to process claims is also described in the Explanation of Payment (EOP) remarks section. Please resubmit the claim with comments, documents, records and other supporting information for review within timely filing guidelines.
If you believe this claim was denied in error: For your convenience, you may file a dispute of our action or decision by selecting the “Take Action” button on this claim via the provider portal. Be sure to provide a clear explanation of the basis for your belief that the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment, or other action on the claim is incorrect.
Denial – Services billed had a modifier inconsistent with the procedure listed
If your claim was denied due to missing information: You may resubmit the claim with the updated information. The data needed to process claims is also described in the Explanation of Payment (EOP) remarks section. Please resubmit the claim with comments, documents, records and other supporting information for review within timely filing guidelines.
If you believe this claim was denied in error: For your convenience, you may file a dispute of our action or decision by selecting the “Take Action” button on this claim via the provider portal. Be sure to provide a clear explanation of the basis for your belief that the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment, or other action on the claim is incorrect.
