Appeal summary
Claim RHP100523. 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
- 999031177032
- Practice claim number
- RHP100523
- Date of service
- Aug 22, 2026
- Rendering provider
- Dr. Victor Adeyemi
- Location
- Riverside Orthopedics
- Payment trace
- SM9990031177, Sep 8, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 29827 | Refused | $2,520.00 | $1,050.00 | $0.00 | $0.00 | $1,050.00 |
| Total | $2,520.00 | $1,050.00 | $0.00 | $0.00 | $1,050.00 | |
Reason and remark codes on the remittance
- CO-197 (adjustment reason), $2,520.00: Contractual obligation. Authorization or notification was required and not on file.
Basis for the request
If authorization was obtained, appeal with the number. If not, write off; it cannot be billed to the patient.
The practice asks the payer to reprocess this claim at the contracted rate: $1,050.00 below contract on the lines above.