Corrected claim summary
Claim RHP100106. Send a corrected claim.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Corrected claim due by Nov 3, 2026 (90 days from the date of service, per contract).
- Payer
- Tallow Creek Health Plan
- Payer ID
- 99901
- Payer claim number
- 999010411006
- Practice claim number
- RHP100106
- Date of service
- Aug 5, 2026
- Rendering provider
- Dr. Alana Reyes
- Location
- Eastgate Family Care
- Payment trace
- EFT9990000411, Aug 24, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99214 | 99214 | $312.00 | $169.00 | $169.00 | $169.00 | $0.00 |
| 20610 | Refused | $156.00 | $84.50 | $0.00 | $0.00 | $84.50 |
| Total | $468.00 | $253.50 | $169.00 | $169.00 | $84.50 | |
Reason and remark codes on the remittance
- CO-45 (adjustment reason), $143.00: Contractual obligation. The charge is higher than the fee schedule or contracted amount. The difference is written off.
- CO-97 (adjustment reason), $156.00: Contractual obligation. Payment for this service is included in another service on the same day.
- M15 (remark): Separately billed services were bundled as parts of the same procedure.
Basis for the request
If the service was separate and distinct, add the right modifier and send a corrected claim.
The practice asks the payer to reprocess this claim at the contracted rate: $84.50 below contract on the lines above.