Denials
July- September 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 Alabama, Georgia and Tennessee.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
Auto Denial - Requested Records not Submitted |
53 |
|
|
2 |
Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services |
8 |
|
|
3 |
LCD Denial - no medical necessity |
4 |
|
|
4 |
No Valid Certification/Recertification Present |
3 |
|
|
5 |
No Valid Plan of Treatment Present |
1 |
|
|
6 |
Need for Service/Item Not Medically and Reasonably Necessary |
1 |
July- September 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 Alabama, Georgia and Tennessee.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
No Diagnosis/Documentation to support medical necessity (Bene Liable/ Provider Liable) |
4801 |
|
|
2 |
No medical necessity |
3672 |
|
|
3 |
Service is subject to prior authorization and no UTN is present on the claim |
83 |
|
|
4 |
NCD Denial - HCPCS/Diagnosis matched National Coverage Determination (NCD) table list ICD9-CM Deny Codes |
80 |
|
|
5 |
Auto Denial - Requested Records not Submitted |
67 |
|
|
6 |
Documentation Submitted Does Not Support Medical Necessity |
43 |
|
|
7 |
Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service |
38 |
|
|
8 |
THE DATE FOR THE ITEM/SERVICE THAT IS SUBJECT TO PRIOR AUTHORIZATION IS AFTER THE EXPIRATION DECISION DATE |
37 |
July - September 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 Alabama, Georgia and Tennessee.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
Agree with Provider (Beneficiary Liable) |
8 |
|
|
2 |
LCD Denial - no medical necessity |
1 |
|
|
3 |
Agree with Provider (Provider Liable) |
1 |