Denials

Published 11/19/2024

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

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