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CRS		CODE SUPERCEDED-AMA CPT GUIDELINES
CRT		CODE SUPERCEDED-AMA CPT GUIDELINES-DENIED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

These explanation codes represent the current set of codes that are returned to the hospital, physician or health care professional on the remittance advice. Please review the translation grid above before calling the Physician & Health Care Hotline for questions about remittance advice codes.