Claims / RHP101139

RHP101139

Silver Mesa Senior Advantage. Visit on Jul 29, 2026 with Jordan Blake, PA-C.

Paid as expected

Charged

$624.00

Contract expects

$260.00

Allowed per fee schedule

Payer allowed

$260.00

Payer paid

$203.84

Patient owes

$52.00

Deductible, coinsurance, copay

At stake

$0.00

What happened

Allowed at the contract rate. The payer paid $203.84 and $52.00 is the patient share.

Claim number matched exactly. Payer status: Processed as primary. Payer claim number 999031102043.

Next step

No action needed

Paid correctly. The patient share goes on the next statement.

Follow-up

Assigned to Nobody yet

Nobody has recorded a follow-up yet.

Line by line

What was billed, what the contract says, and what the payer did with each service.

Service	Charged	Contract	Allowed	Paid	Patient	Adjustments
73721 MRI of a leg joint	$624.00	$260.00	$260.00	$203.84	$52.00	CO-45 Above the contracted rate $364.00 CO-253 Sequestration $4.16 PR-2 Coinsurance $52.00

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The codes on this claim, explained

CO-45Above the contracted rateContract rate

The charge is higher than the fee schedule or contracted amount. The difference is written off.

Contractual obligation: The practice absorbs this amount under its contract or the payer rules. It may not be billed to the patient.

Usual fix: Expected. Only a problem if the allowed amount is below your contract rate.

CO-253SequestrationContract rate

The federal sequestration reduction (currently 2 percent) on Medicare and Medicare Advantage payments.

Contractual obligation: The practice absorbs this amount under its contract or the payer rules. It may not be billed to the patient.

Usual fix: Expected on Medicare business. Not an underpayment.

PR-2CoinsurancePatient share

The patient percentage share of the allowed amount.

Patient responsibility: The patient owes this amount (deductible, coinsurance, copay or a non-covered service the patient agreed to).

Usual fix: Bill the patient for the coinsurance amount shown.

Payment history

Every remittance that answered this claim, oldest first.

Paid	Payment	Result	Status	Paid
Aug 13, 2026	SM9990031102	Paid as expected	Current	$203.84

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As billed

Payer: Silver Mesa Senior Advantage
Date of service: Jul 29, 2026
Sent to payer: Jul 31, 2026
Provider: Jordan Blake, PA-C
Location: Eastgate Family CareEastgate Family Care, East Region
Patient: SYN-1139 (synthetic reference)