Denials

Published 09/07/2022

April — June 2022, 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 your claims are processed timely. The following information affects providers billing the 11X bill type in Alabama, Georgia and Tennessee.

Rank

Denial Code

Denial Description

# Claims Denied

1

56900

Auto Denial — Requested Records Not Submitted

20

2

5D700

No Valid Plan of Treatment Present

2

April — June 2022, 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 your claims are processed timely. The following information affects providers billing the 21X bill type in Alabama, Georgia and Tennessee.

Rank

Denial Code

Denial Description

# Claims Denied

1

5D002

Agree with Provider (Beneficiary Liable)

9

2

5D011

Agree with Provider (Provider Liable)

2

3

5D509

No Qualifying Hospital Stay Dates Were Shown in HIMR for This Skilled Nursing Facility Stay

1

4

5D510

Skilled Nursing Facility benefits Are Only Available After an Eligible Covered Hospital Stay of at Least 3 Days

1

April — June 2022, 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 your claims are processed timely. The following information affects providers billing the 13X bill type in Alabama, Georgia and Tennessee.

Rank

Denial Code

Denial Description

# Claims Denied

1

56900

Auto Denial — Requested Records Not Submitted

729

2

5H164

Documentation Submitted Does Not Support Medical Necessity

364

3

5OP70

Service is Subject to Prior Authorization and No UTN is Present on the Claim.

The Program Indicator is Present. The Beneficiary has No Prior Authorization  Auxiliary File

134

4

5D164

Documentation Submitted Does Not Support Medical Necessity

79

5

5H199

Billing Error for Hospital

78

6

5H165

No Certification

65

5D509 — No Qualifying Hospital Stay Dates Were Shown in HIMR for This Skilled Nursing Facility Stay

Reason for Denial
The service(s) billed was/were not covered by Medicare, as there is no qualifying hospital dates shown in Health Insurance Maintenance Record (HIMR) for this skilled nursing facility.

To Prevent This Denial
The three consecutive calendar-day stay requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. In addition, the qualifying hospital stay must be medically necessary.