Horizon NJ BCBS denial reason list with description

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CRS             CODE SUPERCEDED-AMA CPT GUIDELINES
CRT            CODE SUPERCEDED-AMA CPT GUIDELINES-DENIED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

Posted in: bcbs appeal,denial reason