Appeal summary
Claim RHP101121. Appeal.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 6, 2026
Appeal due by Oct 11, 2026 (60 days from remittance, per contract).
- Payer
- Silver Mesa Senior Advantage
- Payer ID
- 99903
- Payer claim number
- 999031102025
- Practice claim number
- RHP101121
- Date of service
- Jul 28, 2026
- Rendering provider
- Dr. Tomas Varga
- Location
- Riverside Orthopedics
- Payment trace
- SM9990031102, Aug 12, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 29881 | Refused | $1,728.00 | $720.00 | $0.00 | $0.00 | $720.00 |
| Total | $1,728.00 | $720.00 | $0.00 | $0.00 | $720.00 | |
Reason and remark codes on the remittance
- CO-50 (adjustment reason), $1,728.00: Contractual obligation. The payer decided the service was not medically necessary.
- N130 (remark): Check the plan benefit documents for restrictions on this service.
Basis for the request
Appeal with the visit note and any supporting records.
The practice asks the payer to reprocess this claim at the contracted rate: $720.00 below contract on the lines above.