Corrected claim summary
Claim RHP100108. Send a corrected claim.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Corrected claim due by Oct 13, 2026 (90 days from the date of service, per contract).
- Payer
- Tallow Creek Health Plan
- Payer ID
- 99901
- Payer claim number
- 999010411008
- Practice claim number
- RHP100108
- Date of service
- Jul 15, 2026
- Rendering provider
- Dr. Martin Osei
- Location
- Main Campus
- Payment trace
- EFT9990000411, Aug 24, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 71046 | Refused | $84.00 | $45.50 | $0.00 | $0.00 | $45.50 |
| 99214 | Refused | $312.00 | $169.00 | $0.00 | $0.00 | $169.00 |
| Total | $396.00 | $214.50 | $0.00 | $0.00 | $214.50 | |
Reason and remark codes on the remittance
- CO-16 (adjustment reason), $396.00: Contractual obligation. The claim is missing information or has a billing error. A remark code usually says which field.
- MA130 (remark): The claim was incomplete or invalid and has no appeal rights. Submit a new, corrected claim.
Basis for the request
Read the remark code, fix the field it names, and resubmit.
The practice asks the payer to reprocess this claim at the contracted rate: $214.50 below contract on the lines above.