Corrected claim summary
Claim RHP100744. Send a corrected claim.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Corrected claim due by Dec 1, 2026 (90 days from the date of service, per contract).
- Payer
- Tallow Creek Health Plan
- Payer ID
- 99901
- Payer claim number
- 999010498052
- Practice claim number
- RHP100744
- Date of service
- Sep 2, 2026
- Rendering provider
- Dr. Samuel Ivers
- Location
- Main Campus
- Payment trace
- EFT9990000498, Sep 22, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 99203 | Refused | $269.00 | $145.60 | $0.00 | $0.00 | $145.60 |
| Total | $269.00 | $145.60 | $0.00 | $0.00 | $145.60 | |
Reason and remark codes on the remittance
- CO-4 (adjustment reason), $269.00: 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: $145.60 below contract on the lines above.