Denials

Published 11/21/2023

July- September 2023, 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

53

2

5D800

Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services

8

3

55503

LCD Denial - no medical necessity

4

4

5D650

No Valid Certification/Recertification Present

3

5

5D700

No Valid Plan of Treatment Present

1

6

5J504

Need for Service/Item Not Medically and Reasonably Necessary

1


July- September 2023, 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)

4801

2

55504/55503

No medical necessity

3672

3

5OP70

Service is subject to prior authorization and no UTN is present on the claim

83

4

52NCD

NCD Denial - HCPCS/Diagnosis matched National Coverage Determination (NCD) table list ICD9-CM Deny Codes

80

5

56900

Auto Denial - Requested Records not Submitted

67

6

5D164/5H164

Documentation Submitted Does Not Support Medical Necessity

43

7

5OP62

Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service

38

8

5OP64

THE DATE FOR THE ITEM/SERVICE THAT IS SUBJECT TO PRIOR AUTHORIZATION IS AFTER THE EXPIRATION DECISION DATE

37

July - September 2023, 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)

8

2

55503

LCD Denial - no medical necessity

1

3

5D011

Agree with Provider (Provider Liable)

1


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