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 South Carolina, North Carolina, Virginia and West Virginia.

Rank Denial Code Denial Description No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 36
2 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 17
3 55503 LCD Denial — No Medical Necessity 12
4 5J502 Info Submitted Does Not Support Dates Billed 2

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 South Carolina, North Carolina, Virginia and West Virginia.

Rank Denial Code Denial Description No. of Claims
1 55504, 55503 No Medical Necessity 4,826
2 5OP70 Service Is Subject to Prior Authorization and No UTN is Present on the Claim 364
3 5OP62 Item of Service is Subject to Prior Authorization and No Prior Authorization was Requested for the Item of Service 141
4 5OP64 The Date for the Item/Service That Is Subject to Prior Authorization Is after the Expiration Decision Date 55
5 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 31
6 56900 Auto Denial — Requested Records Not Submitted 25

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 South Carolina, North Carolina, Virginia and West Virginia.

Rank Denial Code Denial Description No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 45
2 5D505 Certification Not Valid 8
3 5D504, 5H504 Not Medically and Reasonable Necessary 8
4 5D510 SNF Benefits are Only Available after an Eligible Covered Hospital Stay of at Least 3 Days 7
5 5D002, 5X002 Agree with Provider (Beneficiary Liable) 5
6 5D507 SNF MDS is not in the National Repository 4
7 5D011 Agree with Provider (Provider Liable) 1
8 5H169 Services not Documented 1
9 5D501 Billed in Error 1
10 5D508 Benefits are Exhausted on a SNF Claim for Services Subject to Benefit Period Determinations 1
11 5FFSG Missing or Illegible Signature 1

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