Denials

Published 11/19/2024

Table 1: July through September 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 South Carolina, North Carolina, Virginia and West Virginia.

Rank Denial Code Denial Description No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 33
2 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 28
3 5J502 Info Submitted Does Not Support Dates Billed 5
4 55503 LCD Denial — No Medical Necessity 11
5 5D650 No Valid Certification/Recertification Present 1
6 5D800 Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services 1

Table 2: July throughj 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 South Carolina, North Carolina, Virginia and West Virginia.

Rank Denial Code Denial Description No. of Claims
1 55504, 55503 No Medical Necessity 4,836
2 5OP70 Service Is Subject to Prior Authorization and No UTN Is Present on the Claim 381
3 5OP62 Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service 184
4 5OP64 The Date for the Item/Service That Is Subject to Prior Authorization Is After the Expiration Decision Date 54
5 56900 Auto Denial — Requested Records Not Submitted 46
6 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 26

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 21X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank Denial Code Denial Description # Claims
1 56900 Auto Denial — Requested Records Not Submitted 27
2 5D002, 5X002 Agree with Provider (Beneficiary Liable) 8
3 55503 LCD Denial — No Medical Necessity 5
4 5D505 Certification Not Valid 5
5 5D507 SNF MDS Is Not in the National Repository 4
6 5D504, 5H504 Not Medically and Reasonable Necessary 3
7 5D510 SNF Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least 3 Days 1

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