Denials

Published 03/18/2024

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

52NCD

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.

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