Corrected claim summary
Claim RHP100432. Send a corrected claim.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Corrected claim due by Feb 2, 2027 (180 days from the date of service, per contract).
- Payer
- Granite Plains Mutual
- Payer ID
- 99902
- Payer claim number
- 999020587042
- Practice claim number
- RHP100432
- Date of service
- Aug 6, 2026
- Rendering provider
- Dr. Samuel Ivers
- 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 | Refused | $221.00 | $108.56 | $0.00 | $0.00 | $108.56 |
| 36415 | Refused | $7.00 | $3.54 | $0.00 | $0.00 | $3.54 |
| Total | $228.00 | $112.10 | $0.00 | $0.00 | $112.10 | |
Reason and remark codes on the remittance
- CO-4 (adjustment reason), $228.00: 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: $112.10 below contract on the lines above.