CARC 24: Charges are covered under a capitation agreement/contract
Your provider is paid a fixed monthly rate for your care, so no additional fee-for-service payment is made.
What this means for your claim
Under capitation arrangements (common in HMOs), a provider receives a flat payment per enrolled patient per month regardless of services. Individual claim charges are bundled into that payment.
What to do next
- 1
Verify with your insurer whether this provider is indeed capitated under your plan.
- 2
If you're in an HMO, check whether you need a referral to see this provider or if the service falls outside the capitation scope.
- 3
Contact member services if you're receiving a balance bill from a capitated provider — they typically cannot bill you separately.
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