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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