Denials
Table 1: July through Septenber 2024, Inpatient Hospital and Psych Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 11X bill type in Alabama, Georgia and Tennessee.
| Rank | Denial Code |
Denial Description |
No. of Claims |
|---|---|---|---|
| 1 | 56900 | Auto Denial — Requested Records Not Submitted | 34 |
| 2 | 5CHGE | DRG Code Changed to Reflect Actual Service Billed (Upcode) | 8 |
| 4 | 55503 | LCD Denial — No Medical Necessity | 4 |
Table 2: July through September 2024, Outpatient Services Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 13X bill type in Alabama, Georgia and Tennessee.
| Rank | Denial Code | Denial Description | No. of Claims |
|---|---|---|---|
| 1 | 55503, 55504 | No Medical Necessity | 4,308 |
| 2 | 5OP70 | Service Is Subject to Prior Authorization and No UTN Is Present on the Claim | 189 |
| 3 | 5OP62 | Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service | 158 |
| 4 | 56900 | Auto Denial — Requested Records Not Submitted | 94 |
| 5 | 5D164, 5H164 | Documentation Submitted Does Not Support Medical Necessity | 92 |
| 6 | 5D165, 5H165 | The Documentation Submitted Did Not Include the Required Certifications or Recertification | 24 |
| 7 | 5OP64 | Date for the Item or Service That Is Subject to Prior Authorization Is After the Expiration Decision Date | 11 |
| 8 | 5D169, 5H169 | Services Not Documented | 11 |
| 9 | 5OP68 | Service Is Subject to Prior Authorization and No UTN Is Present on the Claim | 9 |
| 10 | 5OP69 | Service Is Subject to Prior Authorization and No UTN Is Present on the Claim | 8 |
| 11 | 5H199 | Billing Error | 6 |
| 12 | 5CFSG | Missing or Illegible Signature | 1 |
| 13 | 5H151 | Units Billed More than Ordered | 1 |
| 14 | 5H162 | No Valid Plan of Care | 1 |
| 15 | 5H920 | The Recommended Protocol Was Not Ordered and/or Followed | 1 |
Table 3: July through September 2024, Skilled Nursing Facility Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 13X bill type in Alabama, Georgia and Tennessee.
| Rank | Denial Code | Denial Description | No. of Claims |
|---|---|---|---|
| 1 | 56900 | Auto Denial — Requested Records Not Submitted | 31 |
| 2 | 5D504, 5H504 | Not Medically and Reasonably Necessary | 6 |
| 3 | 5D505 | Certification Not Valid | 5 |
| 4 | 5D002, 5X002 | Agree with Provider (Beneficiary Liable) | 3 |
| 5 | 5D501 | Billed In Error | 2 |
| 6 | 5D510 | Skilled Nursing Facility Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least 3 Days | 2 |
| 7 | 55503 | LCD Denial — No Medical Necessity | 1 |
| 8 | 5D507 | SNF MDS Is Not in the National Repository | 1 |