Denials
January 2024 – March 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 Alabama, Georgia and Tennessee.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
56900 |
Auto Denial — Requested Records Not Submitted |
44 |
|
2 |
5CHGE |
DRG Code Changed to Reflect Actual Service Billed (Upcode) |
12 |
|
3 |
55503 |
LCD Denial — No Medical Necessity |
3 |
|
4 |
5D650 |
No Valid Certification/Recertification Present |
1 |
|
5 |
5D700 |
No Valid Plan of Treatment Present |
1 |
|
6 |
5J503 |
Need for Service/Item Not Medically and Reasonably Necessary |
1 |
January 2024 – March 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 Alabama, Georgia and Tennessee.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
55503/55504 |
No Medical Necessity |
3870 |
|
2 |
5OP70 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
192 |
|
3 |
56900 |
Auto Denial — Requested Records Not Submitted |
137 |
|
4 |
5OP62 |
Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service |
132 |
|
5 |
5D164/5H164 |
Documentation Submitted Does Not Support Medical Necessity |
79 |
|
6 |
5OP64 |
Date for the Item or Service That Is Subject to Prior Authorization Is After the Expiration Decision Date |
15 |
|
7 |
5D165/5H165 |
The Documentation Submitted Did Not Include the Required Certifications or Recertification |
13 |
|
8 |
5H169 |
Services Not Documented |
11 |
|
9 |
5OP68 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
11 |
|
10 |
5H151 |
Units Billed More than Ordered |
6 |
|
11 |
5H199 |
Billing Error |
6 |
|
12 |
5H920 |
The Recommended Protocol Was Not Ordered and/or Followed |
3 |
|
13 |
5CFSG |
Missing or Illegible Signature |
1 |
|
14 |
5H162 |
No Valid Plan of Care |
1 |
|
15 |
5HMDP |
Dependent Services or Items Denied Because Service Was Denied Medically |
1 |
|
16 |
5OP69 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
1 |
January 2024 – March 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 Alabama, Georgia and Tennessee.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
55503/55504 |
No Medical Necessity |
3870 |
|
2 |
5OP70 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
192 |
|
3 |
56900 |
Auto Denial — Requested Records Not Submitted |
137 |
|
4 |
5OP62 |
Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service |
132 |
|
5 |
5D164/5H164 |
Documentation Submitted Does Not Support Medical Necessity |
79 |
|
6 |
5OP64 |
Date for the Item or Service That Is Subject to Prior Authorization Is After the Expiration Decision Date |
15 |
|
7 |
5D165/5H165 |
The Documentation Submitted Did Not Include the Required Certifications or Recertification |
13 |
|
8 |
5H169 |
Services Not Documented |
11 |
|
9 |
5OP68 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
11 |
|
10 |
5H151 |
Units Billed More than Ordered |
6 |
|
11 |
5H199 |
Billing Error |
6 |
|
12 |
5H920 |
The Recommended Protocol Was Not Ordered and/or Followed |
3 |
|
13 |
5CFSG |
Missing or Illegible Signature |
1 |
|
14 |
5H162 |
No Valid Plan of Care |
1 |
|
15 |
5HMDP |
Dependent Services or Items Denied Because Service Was Denied Medically |
1 |
|
16 |
5OP69 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
1 |