Horizon NJ Health Denial Code List

Horizon NJ Health Denial Code List

  Remark and Denial Codes


Remark  Denial  Description 
CDD
DEFINITE DUPLICATE CLAIM
CRS
CODE SUPERCEDED-AMA CPT GUIDELINES
CRT
CODE SUPERCEDED-AMA CPT GUIDELINES-DENIED
F47
PAYMENT REFLECTS COB, IF $0, MAXIMUM LIABILITY WAS MET
F50
CLAIM ADJ - THIRD PARTY DENIED OR BENEFITS EXHAUSTED
I02 X02 ILLEGIBLE RECORDS SUBMITTED; REFILE
I04 X04 CORRECT NDC CODE REQUIRED FOR CONSIDERATION
I05 X05 INVALID/DELETED CODE, MODIFIER OR DESCRIPTION
I06 X06 ITEMIZED BILL/DATES OF SERVICE/CHARGES/ INVOICE REQUIRED
I08 X08 DIAGNOSIS INVALID/MISSING/DELETED REQUIRED 4TH/5TH DIGIT
I10
E-CODE CANNOT BE USED AS PRIMARY DIAGNOSIS
I11 X11 EOB FROM PRIMARY CARRIER REQUIRED
I18
PAID BILLED CHARGES
I19 X19 CARRIER OF SERVICE-HORIZON HEALTHCARE DENTAL SERVICE
I22 X22 RESUBMIT WITH VISIT CODES & CHARGES 
I24 X24 CARRIER OF SERVICE-DAVIS VISION 
I26 X26 EXHAUSTION OF BENEFITS
I27 X27 SUBMIT MEDICAL RECORDS TO HORIZON NJ HEALTH APPEALS UNIT 
I28
REPROCESSED-CLAIM SUBJECT TO INTEREST 
I30 X30 SERVICE EXCEEDS LIFETIME LIMITATION 
I37  X37 RESUBMIT WITH APPROPRIATE MODIFIER AND/OR TIME UNITS 
I42 X42 ILLEGIBLE/INCOMPLETE/INAPPROPRIATE REFERRAL RECEIVED
I43 X43 BI-LATERAL PROCEDURE PREVIOUSLY PAID WITH MODIFIER “50”
I44 X44 RESUBMIT WITH ICD/9 PRINCIPLE PROCEDURE CODE 
I47 X47 NON CONTRACTED LEVEL OF CARE
I48 Z48 RESUBMIT TO PRIMARY CARRIER FOR APPEALS PROCESS
I64 X64 CAPITATED TO ANOTHER PROVIDER
I65
DUPLICATE CLAIM-PREVIOUSLY DENIED APPROPRIATELY 
I68
INVALID PLACE OF SERVICE FOR PROCEDURE
I83 X83 MOTHER’S BILL NOT RECEIVED – REFILE
I98
TOTAL BILLED STILL UNDER CONSIDERATION

N02 REDUNDANT PROCEDURE DISALLOW

N06 ASSISTANT SURGEON DISALLOW

Q17 ADMINISTRATIVE OVERTURN
R00 X00 PAYMENT INCLUDED IN OTHER BILLED SERVICES
R01 X01 NO PRECERT/AUTHORIZATION OR REFERRAL
R07 X07 RECEIVED AFTER TIMELY FILING TIME LIMIT 
R09 X09 REQUESTED HOSPITAL DOCUMENTS NOT RECEIVED 
R10 X10 NOT ENROLLED ON DATE OF SERVICE
R15
SUBSET/INCIDENTAL PROCEDURE DISALLOW
R18
RESUBMIT WITH ICD PRINCIPAL PROCEDURE, HCPCS OR CPT CODE
R37
COMBINED PAYMENT-MOTHER & BABY 
R38
CONTRACTED FEE
R39 X39 DUPLICATE CLAIM PREVIOUSLY PAID AT CORRECT RATE OR CAPITATION
R40 X40 DUPLICATE CLAIM-ORIGINAL STILL UNDER CONSIDERATION 
R42
DRG PAYMENT 
R43
INTERIM BILL PAYMENT 
R44
MULTIPLE SURGICAL REDUCTION
R45 X45 COMPLETE MED RECORDS REQUIRED FOR CONSIDERATION; REFILE
R46 X46 OVER MAX PROCEDURE/BENEFIT LIMIT (All LOBs)
R47
PAYMENT REFLECTS COORDINATION OF BENEFITS, IF $0, MAX LIABILITY MET 
R49 X49 PREVIOUS PYMTS EQUAL TO PURCHASE PRICE 
R50 X50 SAME PROCEDURE PAID TO A DIFFERENT PROVIDER 
R51 X51 SERVICE NOT COVERED 
R53 X53 SERVICES WERE NOT PROVIDED
R55
BILLED INFORMATION REFLECTS LOWER DEGREE ACUITY/TREATMENT
R56
ADMINISTRATIVE APPROVAL 
R59 X59 AUTHORIZATION/REFERRAL EXPIRED 
R60 X60 DATES AND/OR SERVICES OUTSIDE REFERRAL/AUTHORIZATION
R61 X61 NO PCP REFERRAL 
R65
INTERIM BILL 2ND CYCLE PAYMENT 
R66 Z34 INTERIM BILL FINAL CYCLE PAYMENT 
R67 X67 DISCREPANCY WITH LEVEL OF CARE-APPEAL REQUIRED
R70 X70 EPSDT SCREENING DID NOT COMPLY WITH PERIODICITY SCHEDULE 
R71 X71 DUPLICATE OF PREVIOUSLY SUBMITTED EPSDT SCREENING 
R72 X72 PROVIDER WAS NOT MEMBER’S PCP 
R78 R78 MEMBER’S AGE NOT VALID FOR PROCEDURE CODE
R79 X79 SPECIAL PROJECT-ADJUSTMENT 
R81 X81 CHARGES CONSIDERED INCLUDED IN INPATIENT ADMISSION 
R84 X84 PLEASE OBTAIN INDIVIDUAL PROVIDER ID #
R86 X85 INVALID/MISSING REVENUE CODE ON CLAIM
R89
AUTHORIZATION ON FILE FOR TECHNICAL COMPONENT 
R91 X91 INAPPROPRIATE CODING FOR CONTRACT AGREEMENT
R95 X95 CLAIM SUBMITTED WITHOUT PHYSICIAN NAME
R96 X96 EOB/ATTACHMENTS WERE INCOMPLETE/ILLEGIBLE
R97 X97 DATE OF SERVICE CANNOT BE GREATER THAN THE RECEIVED DATE

X12 MOTOR VEHICLE ACCIDENT - AUTO CARRIER PRIMARY

X13 WORKERS COMPENSATION PRIMARY CARRIER

X21 BILL THROUGH PHARMACY PROGRAM

X25 INCLUDED IN SETTLEMENT PAYMENT

X32 APPEAL – DENIAL UPHELD

X33 APPEAL – ORIGINAL CLAIM PAYMENT UPHELD

X35 AUTHORIZATION DENIED FOR THIS DATE OF SERVICE

X55 MEMBER AGE NOT VALID FOR DIAGNOSIS CODE

X56 CLINIC CLAIM SUBMITTED WITHOUT PHYSICIAN NAME

X57 THIS “V” DIAGNOSIS CANNOT BE BILLED ALONE

X62 INVALID/MISSING DRG
X68 X68 INVALID UNITS SUBMITTED

X77 INCORRECT PROVIDER NAME/TIN IDENTIFICATION # SUBMITTED

X94 PROVIDER NUMBER SUBMITTED VIA EDI INCORRECT/TERMINATED 
X78 X78 COMBINED PAYMENT – MOTHER AND BABY
Z19 Z19 CARRIER FOR SERVICE-HORIZON BLUE
Z47 Z47 SUBMIT CHARGES TO MA FEE-FOR-SERVICE PROGRAM

Z50 SUBMIT CHARGES TO MEDICAID FEE FOR SERVICE PROGRAM

Z92 INVALID OR MISSING PLACE OF SERVICE
Z99 Z99 CODE NOT PAYABLE FOR PROVIDER SPECIALTY NO FEE ON FILE

Z55 NOT AUTHORIZED UNDER CONTRACT TO PROVIDE THIS SERVICE

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