Medical Review Denials

October – December, 2019, JJ Part A Denial Codes

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.

RankDenial Code# Claims Denied

Denial Code Description

1

56900

Auto Denial — Requested Records Not Submitted

33

2

5CHGE

DRG Code Changed to Reflect Actual Service Billed (Upcode)

32

3

55503

LCD Denial — No Medical Necessity

11

4

5J504

Need for Service/Item Not Medically and Reasonably Necessary

9

5

5D800

Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services

2

6

5J503

No Orders for Inpatient Admission

2

7

5D700

No Valid Plan of Treatment Present

1

8

5J502

Info Submitted Does Not Support Dates Billed

1

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.

RankDenial CodeDenial Description# Claims

1

53NCD/54NCD

No Diagnosis/Documentation to Support Medical Necessity (Bene Liable/ Provider Liable)

4,677

2

55504/55503

No Medical Necessity

3,728

3

52NCD

NCD Denial — HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes

96

4

5D164/5H164

Documentation Submitted Does Not Support Medical Necessity

93

5

 56900

Auto Denial — Requested Records Not Submitted

49

6

5D169/5H169

Services Not Documented

26

7

5D165/5H165

No Certification

26

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.

RankDenial CodeDenial Description# Claims

1

56900

Auto Denial — Requested Records Not Submitted

33

2

5D002/5X002

Agree With Provider (Bene Liable)

11

3

5Down

Medical Review Downcode

10

4

5D508 

Benefits are Exhausted on a SNF Claim for Services Subject to Benefit Period Determinations

2

5

5D510

Skilled nursing facility benefits are only available after an eligible covered hospital stay of at least 3 days

1

6

5D011

Agree With Provider (Provider Liable)

1

7

5D504/5H504

Not Medically and Reasonable Necessary

1

Latest Articles

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5J503 - No Orders for Inpatient Admission 02/18/2020
5D199 - Billing Error 12/10/2019
5DMDP - Dependent Services Denied (Qualifying Service Denied Medically) 12/10/2019
5DTDP - Dependent Services Denied (Qualifying Service Denied Technically) 12/10/2019
5H199 - Billing Error 12/10/2019
5HMDP - Dependent Services Denied (Qualifying Service Denied Medically) 12/10/2019
5HTDP - Dependent Services Denied (Qualifying Service Denied Technically) 12/10/2019
54NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable) 11/15/2019
5H507 - SNF MDS Is Not in the National Repository 11/12/2019
5H200 - Therapy Procedure Non-Skilled 11/11/2019
5D002 - Agree With Provider (Beneficiary Liable) 11/07/2019
5D165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification 11/07/2019
5D501 - Billed in Error 11/07/2019
5H161 - No Physician's Orders 11/07/2019
5H162 - Provider Did Not Submit All Records Requested 11/07/2019
5H504 - Not Medically Reasonable and Necessary 11/07/2019
54NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable) 11/06/2019
55504 - Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage Determinations (LCDs) L34428 and L34570 11/06/2019
5D164 - Documentation Does Not Support Medical Necessity 11/06/2019
5H169 - Services Not Documented 11/06/2019
5H920 - The Recommended Protocol Was Not Ordered and/or Followed 11/06/2019
5D503 - Not Medically Reasonable and Necessary 08/06/2019
5D200 - Therapy Procedure Non-Skilled 05/28/2019
52NCD - NCD Denial - HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes 05/22/2019
53NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable) 05/22/2019
55503 - Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage Determinations (LCDs) L34428 and L34570 05/22/2019
56900 - Auto Denial - Requested Records Not Submitted 05/22/2019
5D011 - Agree With Provider (Provider Liable) 05/22/2019
5D161 - No Physician's Orders 05/22/2019
5D162 - Provider Did Not Submit All Records Requested 05/22/2019
5D169 - Services Not Documented 05/22/2019
5D504 - Not Medically Reasonable and Necessary 05/22/2019
5D507 - SNF MDS Is Not in the National Repository 05/22/2019
5D510 - There Was No Evidence of at Least Three Consecutive Day of Inpatient Hospital Stay 05/22/2019
5D650 - No Valid Certification/Recertification Present 05/22/2019
5D700 - No Valid Plan of Treatment Present 05/22/2019
5D800 - Inpatient Psychiatric Services Not Medically Necessary 05/22/2019
5D920 - The Recommended Protocol Was Not Ordered and/or Followed 05/22/2019
5DOWN - Medical Review Downcode 05/22/2019
5H151 - Units Billed More than Ordered 05/22/2019
5H164 - Documentation Does Not Support Medical Necessity 05/22/2019
5H165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification 05/22/2019
5H501 - Billed in Error 05/22/2019
5H508 - Benefits Are Exhausted on a SNF Claim for Services Subject to Benefit Period Determinations 05/22/2019
5J502 - Information Submitted Does Not Support Dates Billed 05/22/2019
5J504 - Need For Services Not Medically and Reasonable Necessary 05/22/2019
5X002 - Agree With Provider (Beneficiary Liable) 05/22/2019
5CHGE - DRG Upcode/Downcode 12/12/2016