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 South Carolina, North Carolina, Virginia and West Virginia.

Table 1: Inpatient Hospital and Psych Top Denial Reason Codes Q1 2026.
Rank Denial Code Denial Description No. of Claims
1 56900 Auto Denial — Requested Records Not Submitted 42
2 55503 LCD Denial — No Medical Necessity 12
3 5CHGE DRG Code Changed to Reflect Actual Service Billed (Upcode) 7
4 5J504 Need for Service/Item Not Medically and Reasonably Necessary 5
5 5J502 Information Submitted Does Not Support Dates Billed 3
6 5D800 Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services 2

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 South Carolina, North Carolina, Virginia and West Virginia.

Table 2: Outpatient Services Top Denial Reason Codes Q1 2026.
Rank Denial Code Denial Description No. of Claims
1 55503, 55504 No Medical Necessity 4,682
2 5OP70 Service Is Subject to Prior Authorization and No UTN is Present on the Claim 388
3 5D164, 5H164 Documentation Submitted Does Not Support Medical Necessity 58
4 5OP62 Item of Service is Subject to Prior Authorization and No Prior Authorization was Requested for the Item of Service 51
5 56900 Auto Denial — Requested Records Not Submitted 39
6 5D162 No Valid Plan of Care 39

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 South Carolina, North Carolina, Virginia and West Virginia.

Table 3: SNF Top Denial Reason Codes Q1 2026.
Rank Denial Code Denial Description No. of Claims
1 5D505 Certification Not Valid 43
2 56900 Auto Denial — Requested Records Not Submitted 26
3 5D501 Billed in Error 25
4 5D002 Agree with Provider (Beneficiary Liable) 11
5 5FFSG Missing or Illegible Signature 8
6 5D510 SNF Benefits are Only Available after an Eligible Covered Hospital Stay of at Least 3 Days 7
7 5D504, 5H504 Not Medically and Reasonable Necessary 5
8 5D507 SNF MDS is not in the National Repository 4
9 5D169, 5H169 Services Not Documented 1
10 5D011 Agree With Provider (Provider Liable) 1

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