Appeal summary
Claim RHP101043. Appeal.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 6, 2026
Appeal due by Oct 2, 2026 (60 days from remittance, per contract). The window closed 4 days ago.
- Payer
- Fernhollow Community Care
- Payer ID
- 99904
- Payer claim number
- 999044301046
- Practice claim number
- RHP101043
- Date of service
- Jul 15, 2026
- Rendering provider
- Jordan Blake, PA-C
- Location
- Eastgate Family Care
- Payment trace
- 99900004301, Aug 3, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 73721 | Refused | $624.00 | $202.80 | $0.00 | $0.00 | $202.80 |
| Total | $624.00 | $202.80 | $0.00 | $0.00 | $202.80 | |
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: $202.80 below contract on the lines above.