Top Denials and Solutions - Q4 2025

(October, November and December of 2025)

This quarterly summary highlights the top five Return to Provider (RTP), rejection, and denial reason codes identified across claims activity, along with key prevention strategies and solutions for Part A. The report focuses on the most frequent processing issues that result in claims being returned, rejected, or denied, and outlines common submission errors that can be corrected prior to resubmission. It also identifies recurring trends that contribute to avoidable claim outcomes and provides essential resources and best practices to support accurate claim submission and reduce future RTPs, rejections, and denials.

Top 5 Return to Provider (RTP)

32243
This claim level reason code is being returned to the provider because one or more for line items were submitted without associated charges.
32614
Medicare claim for mammography services is being returned because the billing provider is not certified to perform them.
34963
Claim submitted attending physician NPI (National Provider Identifier) not valid in PECOS (Provider Enrollment, Chain, and Ownership System).
34977
Address submitted on claim is not an exact match to what is entered in the Provider Enrollment Chain and Ownership System (PECOS).
37098
Federally Qualified Health Center (FQHC) Medicare Advantage (MA) claim is missing the necessary PPS supplemental rate information.

Top 5 Rejection Reason Codes

31992
Medicare denial code indicating that a claim is considered entirely noncovered.
38200
Claim submitted is exact duplicate of previously submitted claim and fields listed above are same on history and processing claim.
38312
FQHC PPS claim submitted line-item date of service (LIDOS) that matches another LIDOS on previously submitted claim for same beneficiary.
39998
Billing error where the revenue code is not compatible with the type of bill submitted.
U5233
Claim submitted services provided during risk Group Health Organization (GHO) period.

Top 5 Denial Reason Codes

31241
Auto denial of claim line(s) submitted with a "GZ" modifier effective with July 1, 2011, dates of service for TOBs 12x, 13x, 14x, 22x, 23x, 32x, 33x, 34x, 71x, 72x, 73x, 74x, 75x, 76x, 77x, 81x, 82x, 83x and 85x.
39721
Requested non-medical Additional Documentation Request (ADR) never received.
39928
All line items on the claim were denied by Medical Review.
5LPDN
Medicare does not pay for service with diagnosis shown on claim, provider liable.
5NBMB
The information provided does not support the need for this service or item.

Resources

Last Updated Mar 09 , 2026