Appeal summary
Claim RHP100835. Appeal.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Appeal due by Mar 28, 2027 (180 days from remittance, per contract).
- Payer
- Granite Plains Mutual
- Payer ID
- 99902
- Payer claim number
- 999020631043
- Practice claim number
- RHP100835
- Date of service
- Aug 31, 2026
- Rendering provider
- Dr. Victor Adeyemi
- Location
- Eastgate Family Care
- Payment trace
- GP99900000631, Sep 29, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 73721 | Refused | $624.00 | $306.80 | $0.00 | $0.00 | $306.80 |
| Total | $624.00 | $306.80 | $0.00 | $0.00 | $306.80 | |
Reason and remark codes on the remittance
- CO-197 (adjustment reason), $624.00: 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: $306.80 below contract on the lines above.