ModerateContractual Obligation (CO)Eligibility & Coverage

CO-22: Care may be covered under a capitation or managed care plan

The service may be covered by a capitated or managed care arrangement. The payer believes that another entity is financially responsible for this service under a capitation or risk-sharing agreement.

Common Causes

  • Patient is enrolled in a capitated managed care plan
  • Service should be billed to the managed care organization, not fee-for-service
  • Incorrect payer/plan billed on the claim
  • Patient changed from managed care to fee-for-service but records not updated

How to Resolve CO-22

  1. 1Verify the patient's current plan type and effective dates
  2. 2If capitated, bill the appropriate managed care entity
  3. 3If the patient has since disenrolled from the managed care plan, submit proof of enrollment status
  4. 4Contact the payer to clarify the capitation arrangement and responsible entity

How to Prevent CO-22 Denials

  • Verify insurance eligibility and plan type before every visit
  • Check for managed care/capitation status during registration
  • Maintain updated payer routing for capitated vs. fee-for-service claims

Related Denial Codes

CO-109Common

Claim not covered by this payer

CO-15Very Common

Authorization required but not obtained

Stop Denials Before They Happen

Greenlight verifies patient eligibility, benefits, and network status automatically before every visit -- catching coverage issues before they become denials.

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