Appeal summary
Claim RHP100123. Appeal.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Appeal due by Nov 7, 2026 (60 days from remittance, per contract).
- Payer
- Silver Mesa Senior Advantage
- Payer ID
- 99903
- Payer claim number
- 999031177003
- Practice claim number
- RHP100123
- Date of service
- Aug 18, 2026
- Rendering provider
- Dr. Samuel Ivers
- Location
- Main Campus
- Payment trace
- SM9990031177, Sep 8, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99214 | 99214 | $312.00 | $130.00 | $130.00 | $101.92 | $0.00 |
| 93000 | Refused | $41.00 | $17.00 | $0.00 | $0.00 | $17.00 |
| Total | $353.00 | $147.00 | $130.00 | $101.92 | $17.00 | |
Reason and remark codes on the remittance
- CO-45 (adjustment reason), $182.00: Contractual obligation. The charge is higher than the fee schedule or contracted amount. The difference is written off.
- CO-253 (adjustment reason), $2.08: Contractual obligation. The federal sequestration reduction (currently 2 percent) on Medicare and Medicare Advantage payments.
- PR-2 (adjustment reason), $26.00: Patient responsibility. The patient percentage share of the allowed amount.
- CO-50 (adjustment reason), $41.00: Contractual obligation. The payer decided the service was not medically necessary.
- N130 (remark): Check the plan benefit documents for restrictions on this service.
Basis for the request
Appeal with the visit note and any supporting records.
The practice asks the payer to reprocess this claim at the contracted rate: $17.00 below contract on the lines above.