Denials

Published 02/23/2023

October – December 2022, 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	# Claims
1	56900	Auto Denial — Requested Records Not Submitted	36
2	5D700	No Valid Plan of Treatment Present	2
3	5D800	Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services	2
4	55503	LCD Denial — No Medical Necessity	1
5	5D650	No Valid Certification/Recertification Present	1

October – December 2022, 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	# Claims
1	53NCD/54NCD	No Diagnosis/Documentation to Support Medical Necessity (Bene Liable/ Provider Liable)	5024
2	55504/55503	No Medical Necessity	3699
3	56900	Auto Denial — Requested Records Not Submitted	351
4	5D164/5H164	Documentation Submitted Does Not Support Medical Necessity	253
5	5OP70	Service Is Subject to Prior Authorization and No UTN Is Present on the Claim	120
6	52NCD	NCD Denial — HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes	110
7	5D165/5H165	No Certification	48
8	5D169/5H169	Services Not Documented	47
9	5D199/5H199	Billing Error for Hospital	38
10	5OP62	Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service	36

October – December 2022, 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 21X bill type in Alabama, Georgia and Tennessee.

Rank	Denial Code	Denial Description	# Claims
1	5D002/5X002	Agree with Provider (Beneficiary Liable)	5
2	5D011	Agree with Provider (Provider Liable)	4
3	55503	LCD Denial — No Medical Necessity	1

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