Denials


January — March 2021, 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

# Claims

1

55503

LCD Denial — No Medical Necessity

9


January — March 2021, 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

5D002

Agree with Provider (Bene Liable)

7

2

55503

LCD Denial — No Medical Necessity

2

3

5D011

Agree with Provider (Provider Liable)

2

4

5X002

Agree with Provider (Bene Liable)

2




5D164 - Documentation Does Not Support Medical Necessity5CHGE - DRG Code Changed to Reflect Actual Service Billed53NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable)5J502 - Information Submitted Does Not Support Dates Billed5H164 - Documentation Does Not Support Medical Necessity5D501 - Billed in Error5D510 - There Was No Evidence of at Least Three Consecutive Day of Inpatient Hospital Stay5D169 - Services Not Documented5D165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H151 - Units Billed More than Ordered5D161 - No Physician's Orders5H169 - Services Not Documented5H507 - SNF MDS Is Not in the National Repository5D920 - The Recommended Protocol Was Not Ordered and/or Followed5H165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H161 - No Physician's Orders5H501 - Billed in Error5D002 - Agree With Provider (Beneficiary Liable)5D507 - SNF MDS Is Not in the National Repository5DOWN - Medical Review Downcode5D800 - Inpatient Psychiatric Services Not Medically Necessary5D162 - Provider Did Not Submit All Records Requested5H504 - Not Medically Reasonable and Necessary56900 - Auto Denial - Requested Records Not Submitted5D504 - Not Medically Reasonable and Necessary5D650 - No Valid Certification/Recertification Present5H162 - Provider Did Not Submit All Records Requested5J504 - Need for Services Not Medically and Reasonably Necessary5D200 - Therapy Procedure Non-Skilled5D503 - Not Medically Reasonable and Necessary5D700 - No Valid Plan of Treatment PresentReason Code 5OP64: Date for the Item or Service That Is Subject to Prior Authorization Is After the Expiration Decision DateReason Code 5OP70: Service Is Subject to Prior Authorization and No UTN Is Present on the ClaimReason Code 5OP69: Service Is Subject to Prior Authorization and No UTN Is Present on the ClaimReason Code 5OP68: Service Is Subject to Prior Authorization and No UTN Is Present on the ClaimReason Code 5OP62: Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of ServiceReason Code 52NCD: NCD Denial: HCPCS, Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny CodesReason Code 55504: Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage DeterminationReason Code 5H199: Billing ErrorReason Code 5DTDP: Dependent Services Denied (Qualifying Service Denied Technically)Reason Code 5D199: Billing ErrorReason Code 5DMDP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 5J503: No Orders for Inpatient AdmissionReason Code 5H920: The Recommended Protocol Was Not Ordered and/or FollowedReason Code 5HDMP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 5H920: The Recommended Protocol Was Not Ordered and/or FollowedReason Code 5HTDP: Dependent Services Denied (Qualifying Service Denied Technically)Reason Code 5X002: Agree with Provider (Beneficiary Liable)Reason Code 5D002 and 5D011: Agree with Provider (Beneficiary Liable) (Provider Liable)Reason Code 5D011: Agree with Provider (Provider Liable)Reason Code 55503: Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage Determination

Last Updated: 08/05/2021