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CARC 274 · CO-274

CARC 274 Denial: Fee/Service not payable per patient Care Coordination arrangement — How to Fix and Appeal

Reviewed by QuickIntell RCM Editorial Team · Last reviewed

Updated

TL;DR

CARC 274 (X12 Fee/Service not payable per patient Care Coordination arrangement). CARC 274 denies because the service is excluded under the patient's care-coordination arrangement (e.g., PCP-gated HMO, value-based primary care model).

Official X12 description

“Fee/Service not payable per patient Care Coordination arrangement.”

Source: X12 Claim Adjustment Reason Codes. The X12 External Code Lists are the single authoritative source for every CARC descriptor — always verify against the current release before building a claim-scrub rule.

What CARC 274 actually means

CARC 274 denies because the service is excluded under the patient's care-coordination arrangement (e.g., PCP-gated HMO, value-based primary care model). Reroute through the proper care-coordination pathway.

Common root causes

  • Service outside the care-coordination arrangement's covered scope.
  • Referral from the care coordinator not on file.

Prevention checklist

  • Care-coordination referral check at scheduling for gated plans.

Appeal strategy — step by step

Most CARC 274 denials clear faster with the right remediation than with a formal appeal. Work the steps in order and escalate only when a lower-effort path has been ruled out.

  1. 1Obtain care-coordinator referral and resubmit.
Sample appeal-letter language for CARC 274
[Provider letterhead] Re: Appeal of CARC 274 — Claim #{claim_number} Member: {member_name} · Member ID: {member_id} Date(s) of Service: {dos} On {remittance_date} this claim was adjusted with CARC 274: "Fee/Service not payable per patient Care Coordination arrangement." We respectfully request reconsideration. The X12 External Code List definition of CARC 274 does not apply to this claim for the following reasons: 1. [Cite the clinical / coding / policy fact that rebuts the adjustment] 2. [Cite the supporting documentation attached — op note, EOB, LCD/NCD citation, NCCI edit indicator, modifier rationale] 3. [Cite the payer's own policy where applicable] Attached: {list supporting documents} Please process payment under the member's benefits. If additional information is required, contact the billing office at {provider_phone} or {provider_email}. Sincerely, {billing_manager_name}, {credentials}

Edit the bracketed fields before sending. This template is a starting point; a payer-specific appeal form may still be required — check the provider portal first.

Payer-specific notes

Payer-specific behavior for CARC 274 publishes here as the QuickIntell anonymized denial ETL ingests sufficient volume. In the meantime, consult the payer directory for the relevant provider manual and appeal form.

How common is CARC 274?

Search demand rank
#243

Out of 306 seeded CARCs, ranked by combined US monthly search volume for "CARC 274", "CO-274 denial", and "denial code 274".

Platform frequency
Pending ETL

Platform frequency ranks publish once the anonymized denial-rate pipeline reaches the publication threshold (strategy §12 Phase 2).

How QuickRCM prevents CARC 274

QuickRCM catches the root causes above before the 837 leaves the clearinghouse:

  • Claim-scrub rules fire on every root cause listed above — the scrub references the same X12 CAS segment logic that drives the denial, so what the payer checks, QuickRCM checks first.
  • When a denial lands, QuickRCM routes it to the correct worker with the documentation bundle already attached (op note, LCD citation, modifier rationale, EOB, primary 835).
  • Appeal templates tuned to each CARC (including this one) pull the supporting facts from the claim and fill the bracketed fields automatically.
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Frequently asked questions — CARC 274

What does CARC 274 mean?

CARC 274 is an X12 Claim Adjustment Reason Code. The official definition is: "Fee/Service not payable per patient Care Coordination arrangement." In plain English, the payer is telling you cARC 274 denies because the service is excluded under the patient's care-coordination arrangement (e.g., PCP-gated HMO, value-based primary care model). Reroute through the proper care-coordination pathway.

How do I resolve a CARC 274 (CO-274) denial?

Start with the most common root cause: Service outside the care-coordination arrangement's covered scope. First step: Obtain care-coordinator referral and resubmit. See the full remediation and appeal checklist on this page before filing a formal appeal.

Is CARC 274 patient responsibility?

No — CARC 274 is typically carried under CO (Contractual Obligation) or OA (Other Adjustment), which means it is the provider's responsibility, not the patient's. Do not bill the patient unless the 835 CAS group code is PR.

What does CARC 274 look like on an EOB or 835 remittance?

On the 835 ERA, CARC 274 appears in Loop 2110 CAS segment as "CAS*CO*274*{amount}". On a paper EOB the same code prints in the Adjustment/Denial Reason column with the X12 description: "Fee/Service not payable per patient Care Coordination arrangement." — usually paired with one or more RARC remark codes in the same remittance line for additional context.

Can CARC 274 be appealed successfully?

Yes — when the root cause does not apply to the specific claim. Overturn rates are strongest when the appeal cites the X12 definition, the payer's own published policy, and documentation that rebuts the payer's rationale. The sample appeal language block above is a starting point; always adapt it to the payer's reconsideration form.

Disclaimer

This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. X12 code descriptors are maintained by the X12 External Code Lists; always verify against the current X12 release and the payer's own published policy before submitting or appealing a claim.