Appeal summary
Claim RHP100104. Appeal.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Appeal due by Nov 22, 2026 (90 days from remittance, per contract).
- Payer
- Tallow Creek Health Plan
- Payer ID
- 99901
- Payer claim number
- 999010411004
- Practice claim number
- RHP100104
- Date of service
- Aug 3, 2026
- Rendering provider
- Dr. Helen Park
- Location
- Riverside Orthopedics
- Payment trace
- EFT9990000411, Aug 24, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99213 | 99213 | $221.00 | $119.60 | $119.60 | $119.60 | $0.00 |
| 20610 | Refused | $156.00 | $84.50 | $0.00 | $0.00 | $84.50 |
| Total | $377.00 | $204.10 | $119.60 | $119.60 | $84.50 | |
Reason and remark codes on the remittance
- CO-45 (adjustment reason), $101.40: Contractual obligation. The charge is higher than the fee schedule or contracted amount. The difference is written off.
- CO-197 (adjustment reason), $156.00: Contractual obligation. Authorization or notification was required and not on file.
Basis for the request
If authorization was obtained, appeal with the number. If not, write off; it cannot be billed to the patient.
The practice asks the payer to reprocess this claim at the contracted rate: $84.50 below contract on the lines above.