Common Denials in Medical Billing 2025

In US Healthcare or RCM process denials play an important role. When a claim refuse to pay by the Insurance company due to some specific reason denial occurred. Each and every denial has specific way of handling. List of denial codes in medical billing is very long but some denials coming very frequently, these are known as Common Denials in Medical Billing and around 50% claims denied due to these common denials. We discussed on common denials and as well as all other denials of medical billing in this article further.

Common denials in Medical Billing

Some denials in USA Healthcare are use very frequently and more than 50% claims denied due to that reason, the list of common denials mentioned as below,

Denial Code 11 – Performed procedure code is not matched with diagnosis used.

Denial Code 16 – Lack Information – Claim denied due to some information lacking, insurance need some more and specific information.

Denial Code 18 – Duplicate Claim – This most common denial. Insurance company deny claim as claim submitted twice or some services matched with same patient other claims.

Denial Code 22 – (Coordination of Benefit issue) – Covered by another payer. Insurance company needs to update COB info as which one is primary and secondary. Need to bill correct payer.

Denial Code 27 – Coverage Terminated – Claim denied due to service rendered after coverage terminated.

Denial Code 29 – Timely filing limit has been expired. Every insurance some specific limit to file the claim, if that limit has passed insurance deny the claim due to this reason.

Denial Code 31- Patient Can’t be identified as our insured. In this denial patient information mismatched with records like policy id number, sex, SSN, or any important information which required to process the claim.

Denial Code 50 – Service is not considered as Medically Necessary Service.

Denial Code 97 – Bundled Services.

Denial Code 197 – Claim denied due to required pre-certification, authorization not received by insurance company.

List of Denial Codes in Medical Billing

Denial Code	Description
1	Deductible Amount
2	Coinsurance Amount
3	Co-payment Amount
4	The procedure code is inconsistent with the modifier used.
5	The procedure code/type of bill is inconsistent with the place of service.
6	The procedure/revenue code is inconsistent with the patient’s age.
7	The procedure/revenue code is inconsistent with the patient’s gender.
8	The procedure code is inconsistent with the provider type/specialty (taxonomy).
9	The diagnosis is inconsistent with the patient’s age.
10	The diagnosis is inconsistent with the patient’s gender.
11	The diagnosis is inconsistent with the procedure.
12	The diagnosis is inconsistent with the provider type.
13	The date of death precedes the date of service.
14	The date of birth follows the date of service.
15	The authorization number is missing, invalid, or does not apply to the billed services or provider.
16	Claim/service lacks information or has submission/billing error(s).
17	Requested information was not provided or was insufficient/incomplete.
18	Exact duplicate claim/service.
19	This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.
20	This injury/illness is covered by the liability carrier.
21	This injury/illness is the liability of the no-fault carrier.
22	This care may be covered by another payer per coordination of benefits.
23	The impact of prior payer(s) adjudication including payments and/or adjustments.
24	Charges are covered under a capitation agreement/managed care plan.
26	Expenses incurred prior to coverage.
27	Expenses incurred after coverage terminated.
29	The time limit for filing has expired.
31	Patient cannot be identified as our insured.
32	Our records indicate the patient is not an eligible dependent.
33	Insured has no dependent coverage.
34	Insured has no coverage for newborns.
35	Lifetime benefit maximum has been reached.
39	Services denied at the time authorization/pre-certification was requested.
40	Charges do not meet qualifications for emergent/urgent care.
44	Prompt-pay discount.
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
49	This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam.
50	These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
51	These are non-covered services because this is a pre-existing condition.
53	Services by an immediate relative or a member of the same household are not covered.
54	Multiple physicians/assistants are not covered in this case.
55	Procedure/treatment/drug is deemed experimental/investigational by the payer.
56	Procedure/treatment has not been deemed ‘proven to be effective’ by the payer.
58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59	Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.
60	Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
61	Adjusted for failure to obtain second surgical opinion
66	Blood Deductible.
69	Day outlier amount.
70	Cost outlier – Adjustment to compensate for additional costs.
74	Indirect Medical Education Adjustment.
75	Direct Medical Education Adjustment.
76	Disproportionate Share Adjustment.
78	Non-Covered days/Room charge adjustment.
85	Patient Interest Adjustment
89	Professional fees removed from charges.
90	Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.
91	Dispensing fee adjustment.
94	Processed in Excess of charges.
95	Plan procedures not followed.
96	Non-covered charge(s).
97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
100	Payment made to patient/insured/responsible party.
101	Predetermination: anticipated payment upon completion of services or claim adjudication.
102	Major Medical Adjustment.
103	Provider promotional discount (e.g., Senior citizen discount).
104	Managed care withholding.
105	Tax withholding.
106	Patient payment option/election not in effect.
107	The related or qualifying claim/service was not identified on this claim.
108	Rent/purchase guidelines were not met.
109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
110	Billing date predates service date.
111	Not covered unless the provider accepts assignment.
112	Service not furnished directly to the patient and/or not documented.
114	Procedure/product not approved by the Food and Drug Administration.
115	Procedure postponed, canceled, or delayed.
116	The advance indemnification notice signed by the patient did not comply with requirements.
117	Transportation is only covered to the closest facility that can provide the necessary care.
118	ESRD network support adjustment.
119	Benefit maximum for this time period or occurrence has been reached.
121	Indemnification adjustment – compensation for outstanding member responsibility.
122	Psychiatric reduction.
128	Newborn’s services are covered in the mother’s Allowance.
129	Prior processing information appears incorrect.
130	Claim submission fee.
131	Claim specific negotiated discount.
132	Prearranged demonstration project adjustment.
133	The disposition of this service line is pending further review.
134	Technical fees removed from charges.
135	Interim bills cannot be processed.
136	Failure to follow prior payer’s coverage rules. (Use only with Group Code OA)
137	Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
139	Contracted funding agreement – Subscriber is employed by the provider of services. Use only with Group Code CO.
140	Patient/Insured health identification number and name do not match.
142	Monthly Medicaid patient liability amount.
143	Portion of payment deferred.
144	Incentive adjustment, e.g. preferred product/service.
146	Diagnosis was invalid for the date(s) of service reported.
147	Provider contracted/negotiated rate expired or not on file.
148	Information from another provider was not provided or was insufficient/incomplete.
149	Lifetime benefit maximum has been reached for this service/benefit category.
150	Payer deems the information submitted does not support this level of service.
151	Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
152	Payer deems the information submitted does not support this length of service.
153	Payer deems the information submitted does not support this dosage.
154	Payer deems the information submitted does not support this day’s supply.
155	Patient refused the service/procedure.
157	Service/procedure was provided as a result of an act of war.
158	Service/procedure was provided outside of the United States.
159	Service/procedure was provided as a result of terrorism.
160	Injury/illness was the result of an activity that is a benefit exclusion.
161	Provider performance bonus
163	Attachment/other documentation referenced on the claim was not received.
164	Attachment/other documentation referenced on the claim was not received in a timely fashion.
166	These services were submitted after this payers responsibility for processing claims under this plan ended.
167	This (these) diagnosis(es) is (are) not covered.
169	Alternate benefit has been provided.
170	Payment is denied when performed/billed by this type of provider.
171	Payment is denied when performed/billed by this type of provider in this type of facility.
172	Payment is adjusted when performed/billed by a provider of this specialty.
173	Service/equipment was not prescribed by a physician.
174	Service was not prescribed prior to delivery.
175	Prescription is incomplete.
176	Prescription is not current.
177	Patient has not met the required eligibility requirements.
178	Patient has not met the required spend down requirements.
179	Patient has not met the required waiting requirements.
180	Patient has not met the required residency requirements.
181	Procedure code was invalid on the date of service.
182	Procedure modifier was invalid on the date of service.
183	The referring provider is not eligible to refer the service billed.
184	The prescribing/ordering provider is not eligible to prescribe/order the service billed.
185	The rendering provider is not eligible to perform the service billed.
186	Level of care change adjustment.
187	Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
188	This product/procedure is only covered when used according to FDA recommendations.
189	Not otherwise classified’ or ‘unlisted’ procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
190	Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
192	Non standard adjustment code from paper remittance.
193	Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
194	Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
195	Refund issued to an erroneous priority payer for this claim/service.
197	Precertification/authorization/notification/pre-treatment absent.
198	Precertification/notification/authorization/pre-treatment exceeded.
199	Revenue code and Procedure code do not match.
200	Expenses incurred during lapse in coverage
201	Patient is responsible for amount of this claim/service through ‘set aside arrangement’ or other agreement.
202	Non-covered personal comfort or convenience services.
203	Discontinued or reduced service.
204	This service/equipment/drug is not covered under the patient’s current benefit plan
205	Pharmacy discount card processing fee
206	National Provider Identifier (NPI) – missing.
207	National Provider Identifier (NPI) – Invalid format
208	National Provider Identifier (NPI) – Not matched.
209	Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected.
210	Payment adjusted because pre-certification/authorization not received in a timely fashion
211	National Drug Codes (NDC) not eligible for rebate, are not covered.
212	Administrative surcharges are not covered
213	Non-compliance with the physician self referral prohibition legislation or payer policy.
215	Based on subrogation of a third party settlement
216	Based on the findings of a review organization
219	Based on extent of injury.
222	Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.
223	Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
224	Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
225	Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
226	Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete.
227	Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete.
228	Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
229	Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X.
231	Mutually exclusive procedures cannot be done in the same day/setting.
232	Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
233	Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
234	This procedure is not paid separately.
235	Sales Tax
236	This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.
237	Legislated/Regulatory Penalty.
238	Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period.
239	Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
240	The diagnosis is inconsistent with the patient’s birth weight.
241	Low Income Subsidy (LIS) Co-payment Amount
242	Services not provided by network/primary care providers.
243	Services not authorized by network/primary care providers.
245	Provider performance program withhold.
246	This non-payable code is for required reporting only.
247	Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
248	Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
249	This claim has been identified as a readmission.
250	The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing.
251	The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim.
252	An attachment/other documentation is required to adjudicate this claim/service.
253	Sequestration – reduction in federal payment
254	Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient’s medical plan for further consideration.
256	Service not payable per managed care contract.
257	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. payment or lack of premium payment). (Use only with Group Code OA)
258	Claim/service not covered when patient is in custody/incarcerated.
259	Additional payment for Dental/Vision service utilization.
260	Processed under Medicaid ACA Enhanced Fee Schedule