Denials

Published 05/16/2024

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

Denials

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