Appeal summary
Claim RHP100449. Appeal.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Appeal due by Feb 28, 2027 (180 days from remittance, per contract).
- Payer
- Granite Plains Mutual
- Payer ID
- 99902
- Payer claim number
- 999020587059
- Practice claim number
- RHP100449
- Date of service
- Aug 7, 2026
- Rendering provider
- Dr. Tomas Varga
- Location
- Riverside Orthopedics
- Payment trace
- GP99900000587, Sep 1, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 29881 | 29881 | $1,728.00 | $849.60 | $773.14 | $773.14 | $76.46 |
| Total | $1,728.00 | $849.60 | $773.14 | $773.14 | $76.46 | |
Reason and remark codes on the remittance
- CO-45 (adjustment reason), $954.86: Contractual obligation. The charge is higher than the fee schedule or contracted amount. The difference is written off.
Basis for the request
Dispute the shortfall against the contracted rate. Attach the fee schedule page.
The practice asks the payer to reprocess this claim at the contracted rate: $76.46 below contract on the lines above.