Denials
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 |