Denials

Published 09/07/2022

April — June 2022, 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 your 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 Denied

1

56900

Auto Denial — Requested Records not Submitted

59

2

5D700

No Valid Plan of Treatment Present

17

3

5D800

Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services

15

4

5D650

No Valid Certification/Recertification Present

12

April — June 2022, 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 your 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 Denied

1

5D002

Agree With Provider (Beneficiary Liable)

8

2

5D510

Skilled Nursing Facility Benefits Are Only Available after an Eligible Covered Hospital Stay of at Least 3 Days

2

3

5D011

Agree With Provider (Provider Liable)

1

3

5X002

Agree With Provider (Beneficiary Liable)

1

April — June 2022, 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 your 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

# Claims Denied

1

56900

Auto Denial — Requested Records not Submitted

355

2

5D164/5H164

Documentation Submitted Does Not Support Medical Necessity

344

3

5OP70

Service is Subject to Prior Authorization and no UTN is Present on the Claim.

The Program Indicator is Present. The Beneficiary has No Prior Authorization Auxiliary File.

222

4

5H165

No Certification

104