Denials
Table 1: April – June 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 |
# Claims |
|
1 |
No medical necessity |
4823 |
|
|
2 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
438 |
|
|
3 |
Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service |
264 |
|
|
4 |
Auto Denial - Requested Records not Submitted |
229 |
|
|
5 |
Documentation Submitted Does Not Support Medical Necessity |
89 |
|
|
6 |
The date for the item/service that is subject to prior authorization is after the expiration decision date |
47 |
Table 2: April – June 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 |
# Claims |
|
1 |
Auto Denial - Requested Records not Submitted |
100 |
|
|
2 |
DRG Code Changed to Reflect Actual Service Billed (Upcode) |
13 |
|
|
3 |
LCD Denial - no medical necessity |
5 |
|
|
4 |
Need for Service/Item Not Medically and Reasonably Necessary |
2 |
|
|
5 |
Info Submitted Does Not Support Dates Billed |
1 |
Table 3 - April – June 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 South Carolina, North Carolina, Virginia and West Virginia.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|
1 |
Auto Denial - Requested Records not Submitted |
136 |
|
|
2 |
Certification Not Valid |
65 |
|
|
3 |
Not Medically and Reasonable Necessary |
43 |
|
|
4 |
Medical Review Downcode |
18 |
|
|
5 |
Missing or Illegible Signature |
11 |
|
|
6 |
Skilled nursing facility benefits are only available after an eligible covered hospital stay of at least 3 days |
8 |
|
|
7 |
LCD Denial - no medical necessity |
6 |
|
|
8 |
SNF MDS is not in the National Repository |
6 |
|
|
9 |
Agree with Provider (Beneficiary Liable) |
5 |
|
|
8 |
Services Not Documented |
5 |