Refund review summary
Claim RHP100107. Review for refund.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Refund review due by Nov 21, 2026 (60 days from remittance, a working default until the contract term is entered).
- Payer
- Tallow Creek Health Plan
- Payer ID
- 99901
- Payer claim number
- 999010498003D
- Practice claim number
- RHP100107
- Date of service
- Aug 6, 2026
- Rendering provider
- Jordan Blake, PA-C
- Location
- Eastgate Family Care
- Payment trace
- EFT9990000498, Sep 22, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99213 | 99213 | $221.00 | $119.60 | $119.60 | $95.68 | $0.00 |
| Total | $221.00 | $119.60 | $119.60 | $95.68 | $0.00 | |
This claim was paid on more than one remittance with no reversal between. The second payment of $95.68 is the amount under review for refund.
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.
- PR-2 (adjustment reason), $23.92: Patient responsibility. The patient percentage share of the allowed amount.
Basis for the request
The payer paid this claim twice. Expect a recoupment, or refund the second payment.
The amounts above are as the payer reported them on the remittance.