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OA-24 Denial Code: Covered Under Capitation Agreement

OA-24 means the charges are covered under a capitation agreement or managed care plan. The provider is paid through a per-member-per-month or similar arrangement rather than per claim, so this service generates no separate payment. The patient is generally not billed.

Code: OA-24 (CARC 24)
Status: Active In use since January 1, 1995; last modified September 30, 2007.
Code set: Claim Adjustment Reason Codes (CARC)
Group codes: OA (Other Adjustment): The common group: the amount is accounted for by the capitation arrangement and isn't assigned to the patient.
CO (Contractual Obligation): Some payers use CO to show the provider accepts the capitation payment in place of fee-for-service. Don't bill the patient.
Official description: Charges are covered under a capitation agreement/managed care plan.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified: September 24, 2026 against the official X12 list.

What OA-24 means

CARC 24 says charges are covered under a capitation agreement or managed care plan. Under capitation, a provider receives a fixed payment per member, usually per month, for a defined set of services. Claims for those services still go to the payer as encounters, but they don’t generate separate payments. The payer reports the charge with OA-24 to show it’s included in the capitation.

For practices with capitation contracts, OA-24 is expected on most covered services. It becomes a problem when a service that should be paid separately comes back as capitated, or when the patient isn’t actually on your panel.

Common causes of OA-24 problems

Carve-out services processed as capitated. Many capitation contracts exclude certain services (for example some injections, labs, or procedures), which are paid fee-for-service instead.
Patient assigned to the wrong provider, so the claim is capitated to a different primary care provider or group.
Provider billing under the wrong group or TIN, linking a fee-for-service provider to a capitated contract.
Enrollment changes where the patient left the plan or changed assignment.

How to handle it

Confirm the patient is on your capitation roster for that month.
Check your contract’s list of capitated and carved-out services.
If the service is capitated, post OA-24 as an adjustment and don’t bill the patient beyond applicable co-payments.
If the service is carved out, contact the payer and request reprocessing under fee-for-service, citing the contract.
If the patient’s assignment is wrong, work with the payer to fix the roster and reprocess.
If the provider or TIN was wrong on the claim, send a corrected claim with resubmission code 7 in box 22.

How to prevent problems

Reconcile capitation rosters monthly against your patient list.
Flag carve-out services in your billing system so they’re tracked for separate payment.
Verify panel assignment before visits for managed care members.
Watch capitated encounters in your remittance data. An ERA Analyzer can separate expected capitation adjustments from true denials.

Specialty notes

Primary care groups and IPAs see OA-24 most. Specialists usually see it only under specialty capitation arrangements. If you aren’t in any capitation arrangement and receive OA-24, contact the payer, since the claim may have been linked to the wrong contract.

Remark codes that may appear with OA-24

N52 (Patient not enrolled in the billing provider's managed care plan on the date of service.): The patient wasn't enrolled in the billing provider's managed care plan on the date of service, a reason to question the capitation assignment.

CO-256 (Service not payable per managed care contract.): Service not payable per the managed care contract, a denial rather than a capitation adjustment.
CO-242 (Services not provided by network/primary care providers.): Services not provided by network or primary care providers.
CO-104 (Managed care withholding.): Managed care withholding, a portion of payment held back under the contract.
CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.): Fee schedule reduction on a fee-for-service claim, as opposed to a capitated one.

OA-24 FAQ

Why submit claims if I'm paid by capitation?

Most capitation contracts require encounter data so the payer can track utilization and quality. The claim documents the service even though payment comes through the capitation.

Can I bill the patient for OA-24?

Generally no, other than applicable co-payments reported separately. The service is covered by the capitation payment.

When should I question OA-24?

When the service is carved out of your capitation contract and should be paid fee-for-service, when the patient isn't assigned to your panel, or when the patient wasn't enrolled in the plan on that date.

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