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)

31407
Fiscal Intermediary Standard System (FISS) edit applied when multiple units are billed with HCPCS code G2025 (telehealth services) on a 71X Rural Health Clinic (RHC) bill type.
32005
The statement covers from date is greater than the provider's effective date on the provider file.
32243
This claim level reason code is being returned to the provider because one or more for line items were submitted without associated charges.
32415
Condition Code "A6" is required when billing a PPV, flu, or COVID-19 vaccine roster bill.
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.
36428
The claim is being returned due to the billing provider not being certified to perform mammography services
38038
Claim submitted is duplicate of previously submitted claim and one of above-mentioned conditions exists.
38200
Claim submitted is exact duplicate of previously submitted claim and fields listed above are same on history and processing claim.
39998
Billing error where the revenue code is not compatible with the type of bill submitted.

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.
54NCD
None of the diagnoses on the claim support the medical necessity of the service, and no documentation to support medical necessity was provided. Deny the service. The provider is liable.
5LPDN
Medicare does not pay for service with diagnosis shown on claim, provider liable.

Resources

Last Updated Mar 09 , 2026