PR-24: Charges are covered under a capitation agreement/managed care plan.
This service is included in a monthly capitated payment the provider or another entity already receives, so no additional fee-for-service payment is made for it.
What the group code means
- PR
- Patient Responsibility. The amount may be billed to the patient.
This CARC is reported under more than one group code depending on the payer and the circumstances: CO, PR.
Why it fires
- The patient is enrolled in a capitated plan where the PCP or IPA is paid a flat per-member fee that is meant to cover this service
- The provider is contracted under a capitation arrangement for this service category
- The service should have been billed to the capitated entity, such as an IPA or medical group, rather than the health plan directly
Corrective actions, ranked
- 1
Confirm the capitation arrangement
Verify whether this specific service is genuinely included in the provider's or the patient's capitation agreement.
- 2
Bill the correct capitated entity
If a different entity, such as an IPA or medical group, holds the capitation risk for this service, submit the claim or encounter data to them instead.
- 3
Submit as encounter data
Many capitated services still require encounter or informational reporting to the health plan even though no separate payment is made.
Is it worth appealing
Rarely appealable to the health plan directly. If payment is owed, it typically must be pursued through the capitated entity, not a formal payer appeal.
Retrieved 2026-07-18.
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DenialPath provides billing and administrative guidance based on published CMS and X12 sources. It is not medical advice, not a coverage determination, and not a guarantee of payment. NCCI and MUE edits are republished quarterly and payer policies vary by contract. Always confirm against the payer's own current policy before submitting or appealing.