Explanation of reason codes and ... - Horizon NJ Health

1 New NDC edits codes effective September 2019 STATE EDITS01 Denial codes (Claims reviewed by examiners)XC Denial codes (Batch process)EOB CodesShort DescriptionLong DescriptionRemarkPrint on EOBCARC /RARC551I85I89 I63 NDC probably obsolete for date of serviceNDC on this claim is no longer valid for the dates of serviceDeny claim Y16/M119 300I82I84 I70 Maximum dosage exceededValidate claims based on the maximum daily dosage exceededDeny claim Y 222/N362215I8AI8BI8 CNDC Healthcare Common Procedure Coding System (HCPCS) mismatchNDC HCPCS codes combination is invalidDeny claimY16/M119 Existing NDC edit implemented in August 2018 STATE EDITS01 Denial codes (Claims reviewed by examiners)XC Denial codes (Batch process)EOB CodesShort DescriptionLong DescriptionRemarkPrint on EOBCARC /RARC214I71 I41I54 NDC Code is invalid/no WAC price in First Data Bank (FDB)NDC number is invalid for date of service or WAC price is not available in FDBDeny claimY16/M119317I72I45I55 NDC quantity is invalidNDC quantity has invalid metric quantityDeny claimY16/M119322I74I50I57 NDC unit of measurement is invalidMust have a valid unit of measure gram (GR), milliliter (ML), units (UN), International Units (F2) and should be valid for the NDC codeDeny claimY16/M119330I75I51I58 NDC quantity exceededQuantity should be valid and calculated allowed amount (quantity X price) should not be more than two times of the billed amountDeny claimY222/N362328I76I52I59 Valid revenue codes are required for this NDCO utpatient drug claims are required revenue codes 631 through 637 or 25xDeny claimY16/M50544I77I53I61 NDC is in Drug Efficacy Study Implementation (DESI)

2 FileNDC is not payable andinvalid in FederalDESI file for the date of serviceDeny claimY16/M119323 NANAI67 Warning NDC not in Maximum Dosage FileWarning NDC is not in Maximum Daily Dosage File for the claims date of serviceWarning Explanation of reason codes and descriptions for the NDC denial codes1 DOS FROM DTDOS to DtProcedureProc UnitsNDCNDC UnitsCharge AmountPaid Amount4/18/20184/18/2018J246956825607970 15$ $ FROM DTDOS to DtProcedureProc UnitsNDCNDC UnitsCharge AmountPaid Amount10/24/201710/24/2017J7050100264180 032264180032$ $ FROM DTDOS to DtProcedureProc UnitsNDCNDC UnitsNDC UOMC harge AmountPaid Amount1/8/20181/8/2018J17455057894003001 1ML$37, $5, 317 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI72I45I55317 NDC quantity is invalidNDC quantity has invalid metric example: The claim/encounter was rejected because the NDC units billed are invalid. The provider billed the NDC code in place of the NDC 322 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI74I50I57322 NDC unit of measurement is invalidMust have a valid UOM F2, GR, ML, UN and should be valid for the NDC example: The claim/encounter was rejected because the NDC UOM was billed as ML, but it should have been billed as edit implemented August 2018 Examples: EDIT 214 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI71I41I54214 NDC code is invalid/no WAC price in FDBNDC number is invalid for date of service or WAC price is not available in example.

3 The claim/encounter was rejected because the NDC code 68256079701 is not a valid NDC 330 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI75I51I58330 NDC quantity exceededQuantity should be valid and calculated allowed amount (quantity X price) should not be more than two times the billed example: The below claim/encounter (Claim ID - 18085F959900 line 1) was rejected because (claim charge amount * 2) is less and this should be more than total NDC price (NDC price * NDC units billed).2 EDIT 328 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI76I52I59328 Valid revenue codes are required for this NDCO utpatient drug claims use revenue codes 631 through 637 or example: The claim/encounter was rejected because the revenue code billed on the outpatient claim was FROM DTDOS to DtProcedureProc UnitsNDCNDC UnitsCharge AmountPaid Amount3/22/20183/22/2018J927120000006302 602200$16, $9, charge amount * 2 g $16,000 * 2 = $32,000 Total NDC Price g $1, * 200 = $229,046In this case, since the (claim charge amount * 2) is less and this should be more than total NDC price (NDC price * NDC units billed) the provider has billed the NDC units example 2: The below claim/encounter (Claim ID - 18247I516300 line 1) was rejected as (claim charge amount * 2) is less and this should be more than total NDC price (NDC price * NDC units billed).

4 DOS FROM DTDOS to DtProcedureProc UnitsNDCNDC UnitsCharge AmountPaid Amount8/30/20188/30/2018J3380 30064764030020300$10, $6, charge amount * 2 g $10,800 * 2 = $21,600 Total NDC Price g $6, * 300 = $1,829,271In this case, since the (claim charge amount * 2) is less and this should be more than total NDC price (NDC price * NDC units billed)the provider has billed the NDC units FROM DTDOS to DtProcedureProc UnitsRevenue codeNDCNDC Units1/29/20181/29/2018J3490402702435707 010620 EDIT 544 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI77I53I61544 NDC is not in DESI fileNDC is not payable and invalid in Federal DESI file for the date of example: The above claim/encounter was rejected because the NDC billed has been classified as a less than effective (LTE) DESI drug effective 11/18/2014, which is lesser than the DOS on the FROM DTDOS to DtProcedureProc UnitsRevenue CodeNDCNDC UnitsCharge AmountPaid Amount8/30/20188/30/2018J3380 30064764030020300$10, $6, $6, 2019 NDC Edits 9 EDIT 300 - Maximum dosage exceededDENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI82I84I70300 Maximum dosage exceededNDC metric quantity reported on the claim exceeds the Maximum Daily Dosage File for the claims date of example: The below claim/encounter was rejected because the NDC metric quantity reported on the claim exceeds the Maximum Daily Dosage File for the claims date of FROM DTDOS to DtProcedureProc UnitsRevenue CodeNDCNDC UnitsCharge AmountPaid Amount2/12/20182/12/2018J9201 $3, $ $6, details for the NDC.

5 NDCMDDE ffective DateTerm Date00002750101206/9/200912/31/9999 EDIT 551 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI85I89I63551 NDC probably obsolete NDC on this claim is obsolete and is no longer valid for the dates of service on this example: The below claim/encounter was rejected because the NDC reported on the claim is obsolete for the claims date of FROM DTDOS to DtProcedureProc UnitsRevenue CodeNDCNDC UnitsCharge AmountPaid Amount12/19/201812/19 $3, $3, $ 215 DENIAL CODE (01 CLAIMS WORKED BY EXAMINERS)Denial Code (Batch Process)EOB CodeState Encounter Edit CodeShort DescriptionLong DescriptionI8AI8BI8C215 NDC HCPCS mismatchNDC HCPCS combination does not match the Centers for Medicare and Medicaid (CMS) example: The below claim/encounter was rejected because the NDC HCPCS combination does not match the CMS FROM DTDOS to DTProcedureProc UnitsNDCNDC UnitsCharge AmountPaid Amount2/16/20192/16/2019J9044 (Injection, bortezomib, not otherwise specified, mg) 3563020004901 (VELCADE MG VIAL)1$4, $1, HCPCS crosswalkJ CODEJ code DescriptionNDCNDC DescriptionJ9044 Injection, bortezomib, not otherwise specified, mg63323072110 BORTEZOMIB MG VIALFor the most recent NDC-HCPCS (J code) cross walk table, visit are provided by Horizon NJ Health .

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