Denials

Published 02/19/2026

Inpatient Hospital and Psych Medical Review Top Denial Reason Codes October through December 2025

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.

Table 1. Inpatient Hospital and Psych Top Denial Reason Codes Q4 2025.
Rank Denial Code Denial Description # Claims
1 56900 Auto Denial — Requested Records Not Submitted 64
2 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 8
3 5D700 No Valid Plan of Treatment Present 5
4 55503 LCD Denial — No Medical Necessity 2
5 5J502 Information Submitted Does Not Support Dates Billed 1

Outpatient Services Medical Review Top Denial Reason Codes October through December 2025

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.

Table 2. Outpatient Services Top Denial Reason Codes Q4 2025.
Rank Denial Code Denial Description # Claims
1 55503, 55504 No Medical Necessity 4,562
2 5OP70 Service Is Subject to Prior Authorization and No UTN is Present on the Claim 103
3 5OP62 Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service 67
4 56900 Auto Denial — Requested Records Not Submitted 57
5 5OP64 Date for the Item or Service that Is Subject to Prior Authorization is After the Expiration Decision Date 56
6 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 40

Skilled Nursing Facility (SNF) Medical Review Top Denial Reason Codes October through December 2025

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.

Table 3. SNF Top Denial Reason Codes Q4 2025.
Rank Denial Code Denial Description # Claims
1 56900 Auto Denial — Requested Records Not Submitted 165
2 5D505 Certification Not Valid 61
3 5D504, 5H504 Not Medically and Reasonably Necessary 49
4 5FFSG Missing or Illegible Signature 37
5 5D501, 5H501 Billed in Error 30
6 5D507 SNF MDS Is Not in the National Repository 16
7 5D510 SNF Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least Three Days 16
8 5D002, 5X002 Agree with Provider (Beneficiary Liable) 6
9 5D169 Services Not Documented 3

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