Denials

Published 06/03/2026

Inpatient Hospital and Psych Medical Review Top Denial Reason Codes January through March 2026

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.

Table 1. Inpatient Hospital and Psych Top Denial Reason Codes Q1 2026.
Rank Denial Code Denial Description # Claims
1 56900 Auto Denial — Requested Records Not Submitted 60
2 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 5
3 5J502 Information Submitted Does Not Support Dates Billed 5
4 55503 LCD Denial — No Medical Necessity 1
5 5J504 Need for Service/Item Not Medically and Reasonably Necessary 1

Outpatient Services Medical Review Top Denial Reason Codes January through March 2026

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.

Table 2. Outpatient Services Top Denial Reason Codes Q1 2026.
Rank Denial Code Denial Description # Claims
1 55503, 55504 No Medical Necessity 3,983
2 5OP70 Service Is Subject to Prior Authorization and No UTN is Present on the Claim 227
3 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 163
4 5OP62 Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service 61
5 5OP64 Date for the Item or Service that Is Subject to Prior Authorization is After the Expiration Decision Date 61
6 56900 Auto Denial — Requested Records Not Submitted 57
7 5H169 Services Not Documented 52
8 5D162, 5H162 No Valid Plan of Care 25
9 5OP69 Service is Subject To Prior Authorization and No UTN is Present on The Claim 16
10 5OP68 Service Is Subject to Prior Authorization and No UTN Is Present on the Claim 12
11 5D165, 5H165 The Documentation Submitted Did Not Include the Required Certifications or Recertification 6
12 5D920, 5H920 The Recommended Protocol Was Not Ordered and/or Followed 6
13 5D199, 5H199 Billing Error 3
14 5H151 Units Billed More Than Ordered 3

Skilled Nursing Facility (SNF) Medical Review Top Denial Reason Codes January through March 2026

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.

Table 3. SNF Top Denial Reason Codes Q1 2026.
Rank Denial Code Denial Description # Claims
1 56900 Auto Denial — Requested Records Not Submitted 162
2 5D505 Certification Not Valid 62
3 5FFSG, 5CFSG Missing or Illegible Provider Signature 21
4 5D504, 5H504 Not Medically and Reasonably Necessary 20
5 5D501, 5H501 Billed in Error 19
6 5D510 SNF Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least Three Days 18
7 5D507 SNF MDS Is Not in the National Repository 15
8 5D002, 5X002 Agree with Provider (Beneficiary Liable) 5
9 5DOWN Medical Review Downcode 5

Was this article helpful?