Appeal summary
Claim RHP100105. 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
- 999010411005
- Practice claim number
- RHP100105
- Date of service
- Aug 4, 2026
- Rendering provider
- Dr. Martin Osei
- Location
- Stonebridge
- Payment trace
- EFT9990000411, Aug 24, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99215 | 99214Recoded by the payer | $439.00 | $237.90 | $169.00 | $169.00 | $68.90 |
| Total | $439.00 | $237.90 | $169.00 | $169.00 | $68.90 | |
Reason and remark codes on the remittance
- CO-45 (adjustment reason), $270.00: Contractual obligation. The charge is higher than the fee schedule or contracted amount. The difference is written off.
Basis for the request
Dispute the shortfall against the contracted rate. Attach the fee schedule page.
The practice asks the payer to reprocess this claim at the contracted rate: $68.90 below contract on the lines above.