Corrected claim summary
Claim RHP100116. Send a corrected claim.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Corrected claim due by Feb 9, 2027 (180 days from the date of service, per contract).
- Payer
- Granite Plains Mutual
- Payer ID
- 99902
- Payer claim number
- 999020587006
- Practice claim number
- RHP100116
- Date of service
- Aug 13, 2026
- Rendering provider
- Dr. Nina Castellano
- Location
- Main Campus
- Payment trace
- GP99900000587, Sep 1, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99213 | 99213 | $221.00 | $108.56 | $108.56 | $108.56 | $0.00 |
| 11102 | Refused | $240.00 | $118.00 | $0.00 | $0.00 | $118.00 |
| Total | $461.00 | $226.56 | $108.56 | $108.56 | $118.00 | |
Reason and remark codes on the remittance
- CO-45 (adjustment reason), $112.44: Contractual obligation. The charge is higher than the fee schedule or contracted amount. The difference is written off.
- CO-4 (adjustment reason), $240.00: Contractual obligation. The procedure code does not agree with the modifier billed, or a required modifier is missing.
Basis for the request
Fix the modifier and send a corrected claim.
The practice asks the payer to reprocess this claim at the contracted rate: $118.00 below contract on the lines above.