OA-274: Fee/Service Not Payable — Care Coordination Arrangement

What Does OA-274 Mean?

OA-274 signals an adjustment under the care coordination arrangement where responsibility is not clearly assigned to the provider or patient. This commonly appears when a service is included in a bundled payment or global fee, making separate reimbursement inappropriate. The adjustment is typically informational and reflects the arrangement's payment structure rather than an error.

CARC 274 fires when a payer determines that the billed fee or service is not payable under the patient's care coordination arrangement. These arrangements — common in ACOs, bundled payment programs, and managed care plans — define specific parameters for covered services, and any service falling outside those parameters triggers this denial.

The root cause is almost always a disconnect between what was billed and what the care coordination agreement actually covers. This can be a genuine coverage exclusion, an expired or missing authorization specific to the arrangement, a service that exceeds frequency limits, or simply a coding error that made a covered service look like a non-covered one. In bundled payment scenarios, the service may already be included in a global fee, making separate billing inappropriate.

Unlike more common denial codes, CARC 274 requires you to understand the specific terms of the patient's care coordination arrangement — not just the standard insurance plan. This means resolution often involves reviewing arrangement-specific documentation rather than standard payer policies.

Common Causes

How to Resolve

Review the care coordination arrangement terms, identify why the service was excluded, and either correct the claim or appeal with supporting documentation.

1. Check bundled payment terms Determine whether the denied service is included in a bundled payment or global fee under the care coordination arrangement.
2. Confirm with the payer Contact the payer to verify whether the adjustment is correct and whether the service can be billed separately.
3. Resubmit if separately payable If the service falls outside the bundle, provide documentation showing it is not included in the global fee and resubmit the claim.

How to Prevent OA-274

• Maintain a clear reference of which services are bundled under each care coordination arrangement
• Verify with the payer before billing services that may be included in a global fee
• Keep records of arrangement terms to quickly determine whether separate billing is appropriate

General Prevention

• Understand which services are bundled under the care coordination arrangement before billing separately
• Verify with the payer whether specific services require separate billing or are included in the global fee
• Maintain clear records of what is and is not included in care coordination bundles

Also Filed As

The same CARC 274 may appear with different Group Codes:

Related Denial Codes