How do I fix or resolve code 24?

Review the provider's managed care contract or capitation agreement to confirm whether the specific service billed is included in the capitated services list. Verify that the patient is enrolled in the capitated plan and that the provider has an active capitation contract with the payer for the date of service. If the service is included in the capitation agreement, write off the charge as a capitated adjustment — the provider has already been paid through the PMPM capitation payment. If the service is not included in the capitation list (e.g., a carve-out service like behavioral health or certain procedures), file a claim reconsideration with the contract citation showing the service is separately billable. If the patient was incorrectly assigned to the capitated plan or the capitation was not in effect for the DOS, contact the payer's provider relations to correct the enrollment and resubmit the claim.

24Adjustment CodeGeneral Adjustment

Code 24

Problem Description

Charges are covered under a capitation agreement/managed care plan.

Root Cause

The charges are covered under a capitation agreement or managed care plan. In a capitated arrangement, the provider receives a fixed monthly payment per member (per member per month, PMPM) regardless of the services rendered, and most services are included in the capitation payment. The payer denies the individual claim because the service is already covered under the capitation agreement — the provider cannot bill the payer on a fee-for-service basis for services included in the capitated contract. This is a contractual adjustment, not a denial for medical necessity or eligibility.

Resolution Steps

1Review the provider's managed care contract or capitation agreement to confirm whether the specific service billed is included in the capitated services list.
2Verify that the patient is enrolled in the capitated plan and that the provider has an active capitation contract with the payer for the date of service.
3If the service is included in the capitation agreement, write off the charge as a capitated adjustment — the provider has already been paid through the PMPM capitation payment.
4If the service is not included in the capitation list (e.g., a carve-out service like behavioral health or certain procedures), file a claim reconsideration with the contract citation showing the service is separately billable.
5If the patient was incorrectly assigned to the capitated plan or the capitation was not in effect for the DOS, contact the payer's provider relations to correct the enrollment and resubmit the claim.

EHR Documentation Note

Claim adjusted 24 — charges covered under capitation agreement; verified capitated services list, posted capitation write-off, or filed reconsideration for carve-out services.

Preventative Action

Maintain a current capitated services list for each managed care contract and train billing staff to identify carve-out services that are separately billable outside the capitation payment.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.