Denials
October – December 2023, 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 | 55504/55503 | No Medical Necessity | 4639 |
2 | 53NCD/54NCD | No Diagnosis/Documentation to Support Medical Necessity (Bene Liable/ Provider Liable) |
3621 |
3 | 56900 | Auto Denial — Requested Records not Submitted | 191 |
4 | NCD Denial — HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes | 139 | |
5 | 5OP70 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim. The Program Indicator Is Present. The Beneficiary Has No Prau Auxiliary File. |
124 |
6 | 5D164/5H164 | Documentation Submitted Does Not Support Medical Necessity | 98 |
7 | 5OP62 | Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service | 58 |
8 | 5OP64 | Item/Service That Is Subject to Prior Authorization Is After the Expiration Date | 32 |
October – December 2023, 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 | 56900 | Auto Denial — Requested Records Not Submitted | 23 |
2 | 55503 | LCD Denial — No Medical Necessity | 19 |
3 | 5J504 | Need for Service/Item Not Medically and Reasonably Necessary | 3 |
4 | 5CHGE | DRG Code Changed to Reflect Actual Service Billed (Upcode) | 1 |
5 | 5D199 | Billing Error for Hospital | 1 |
October – December 2023, 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 | 56900 | Auto Denial — Requested Records Not Submitted | 120 |
2 | 5DOWN | Medical Review Downcode | 78 |
3 | 5D505 | Certification Not Valid | 25 |
4 | 5CHGE | Upcode | 10 |
5 | 5FFSG | Missing or Illegible Signature | 10 |
6 | 5D501 | Billed in Error | 9 |
7 | 5D504/5H504 | Not Medically and Reasonable Necessary | 9 |
8 | 5D510 | Skilled Nursing Facility Benefits Are Only Available After an Eligible Covered hospital Stay of at Least 3 Days | 9 |
9 | 55503 | LCD Denial — No Medical Necessity | 5 |
10 | 5D002/5X002 | Agree with Provider (Beneficiary Liable) | 4 |
5FFSG/5CFSG — Missing or Illegible Provider Signature(s)
Reason for Denial
This claim was fully or partially denied because there were missing or illegible provider signature(s) and a signature log or provider attestation was not received.
How to Avoid This Denial
- A physician’s order or document indicating physician’s intent must be submitted for review with the request for copies of medical records
- A legible signature is required on all documentation necessary to support orders and medical necessity
- A signature log or provider attestation must be submitted for review timely (within 20 calendar days) when requested. The 20 day timeframe begins once either the contractor makes an actual phone contact with the provider, or the date the request letter is received by the post office.
- Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable.
Resources
- Code of Federal Regulations, 42 CFR — Section 410
- CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1 (PDF)
- CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF)
- MLN Matters Article MM 6698 Revised (PDF)