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 South Carolina, North Carolina, Virginia and West Virginia.

Table 1: Inpatient Hospital and Psych Top Denial Reason Codes Q4 2025
Rank Denial Code Denial Description No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 33
2 55503 LCD Denial — No Medical Necessity 14
3 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 12
4 5D800 Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services 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 South Carolina, North Carolina, Virginia and West Virginia.

Table 2: Outpatient Services Top Denial Reason Codes Q4 2025
Rank Denial Code Denial Description No. of Claims
1 55504, 55503 No Medical Necessity 5,262
2 5OP70 Service Is Subject to Prior Authorization and No UTN is Present on the Claim 126
3 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 80
4 5OP62 Item of Service is Subject to Prior Authorization and No Prior Authorization was Requested for the Item of Service 41
5 5H199 Billing Error for Hospital 31
6 56900 Auto Denial — Requested Records Not Submitted 27

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 South Carolina, North Carolina, Virginia and West Virginia.

Table 3: SNF Top Denial Reason Codes Q4 2025
Rank Denial Code Denial Description No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 20
2 5D002 Agree with Provider (Beneficiary Liable) 5
3 5D011 Agree with Provider (Provider Liable) 3
4 5D501 Billed in Error 2
5 5D169, 5H169 Services Not Documented 1
6 5D505 Certification Not Valid 1
7 5D510 SNF Benefits are Only Available after an Eligible Covered Hospital Stay of at Least 3 Days 1

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