Reason Code C5460 - JF Part A

Reason Code Narrative

ITEM OR SERVICE IS SUBJECT TO PRIOR AUTHORIZATION AND A NON-AFFIRMED DECISION IS PRESENT ON THE PRAU AUXILLARY FILE.

Common Reason Code Errors

• Non-affirmed prior authorization request on file for service billed on the claim.

Common Reason Code Corrections

• Auto denial
• A redetermination request may be submitted if facility feels that sending additional documentation will support need for service(s) provided
  • Redetermination should include:
    • All applicable supporting medical documentation
    • Corrected UB-04 form

Resources

• CMS Prior Authorization OPD Guide
• CMS PA OPD FAQ