Claims / RHP100118

RHP100118

Granite Plains Mutual. Visit on Aug 14, 2026 with Dr. Nina Castellano.

Partially denied

Charged

$461.00

Contract expects

$226.56

Allowed per fee schedule

Payer allowed

$108.56

Payer paid

$108.56

Patient owes

$240.00

Includes a service the payer made the patient responsible for

At stake

$118.00

What happened

$240.00 refused, payer reason code PR-96 (the payer made the patient responsible for it): The service is not covered. A remark code usually says why.

Claim number matched exactly. Payer status: Processed as primary. Payer claim number 999020587008.

Next step

Bill the patient

Patient responsibility (group PR): the payer refused this and made the patient responsible. The service is not covered. A remark code usually says why. Confirm the patient has no other coverage for the visit date and that any required waiver or advance notice is on file, then bill the patient.

Follow-up

Assigned to Nobody yet

Nobody has recorded a follow-up yet.

Line by line

What was billed, what the contract says, and what the payer did with each service.

Service	Charged	Contract	Allowed	Paid	Patient	Adjustments
99213 Established patient visit, low complexity	$221.00	$108.56	$108.56	$108.56	$0.00	CO-45 Above the contracted rate $112.44
11102 Skin biopsy Refused	$240.00	$118.00	$0.00	$0.00	$240.00	PR-96 Non-covered charge $240.00

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The codes on this claim, explained

PR-96Non-covered chargeNot covered by the plan

The service is not covered. A remark code usually says why.

Patient responsibility: The patient owes this amount (deductible, coinsurance, copay or a non-covered service the patient agreed to).

Usual fix: Bill the patient only if they signed a waiver or the plan allows it; otherwise write off.

CO-45Above the contracted rateContract rate

The charge is higher than the fee schedule or contracted amount. The difference is written off.

Contractual obligation: The practice absorbs this amount under its contract or the payer rules. It may not be billed to the patient.

Usual fix: Expected. Only a problem if the allowed amount is below your contract rate.

Remark codes: N130 Check the plan benefit documents for restrictions on this service.

Payment history

Every remittance that answered this claim, oldest first.

Paid	Payment	Result	Status	Paid
Aug 31, 2026	GP99900000587	Partially denied	Current	$108.56

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As billed

Payer: Granite Plains Mutual
Date of service: Aug 14, 2026
Sent to payer: Aug 16, 2026
Provider: Dr. Nina Castellano
Location: Main CampusMain Campus, East Region
Patient: SYN-0118 (synthetic reference)