Denials

Published 02/28/2025

Table 1: October through December 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

No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 6
2 55503 LCD Denial — No Medical Necessity 4
4 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 3

Table 2: October through December 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 No. of Claims
1 55503, 55504 No Medical Necessity 4,600
2 5OP70 Service is Subject to Prior Authorization and No UTN Is Present on the Claim 228
3 5OP62 Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service 73
4 56900 Auto Denial — Requested Records Not Submitted 52
5 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 50
7 5OP64 Date for the Item or Service That Is Subject to Prior Authorization Is After the Expiration Decision Date 26

Table 3: October through December 2024, Skilled Nursing Facility (SNF) 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 No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 92
2 5D504, 5H504 Not Medically and Reasonably Necessary 22
3 5D505 Certification Not Valid 7
4 5D510 SNF Benefits Are Only Available after an Eligible Covered Hospital Stay of at Least 3 Days 6
5 5D002, 5X002 Agree with Provider (Beneficiary Liable) 3
6 5D507 SNF MDS Is Not in the National Repository 2
7 5D501/5H501 Billed in Error 2
8 55503 LCD Denial — No Medical Necessity 1
9 5D011 Agree with Provider (Provider Liable) 1
10 5DOWN Medical Review Downcode 1
11 5FFSG Missing or Illegible Signature 1
12 5D509 No Qualifying Hospital Stay Dates Were Shown in HIMR for This SNF Stay 1

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