Corrected claim summary
Claim RHP101212. Send a corrected claim.
Ridgeline Health Partners
Billing NPI 9999999001 (fictional)
Prepared Oct 7, 2026
Corrected claim due by Jan 21, 2027 (180 days from the date of service, per contract).
- Payer
- Granite Plains Mutual
- Payer ID
- 99902
- Payer claim number
- 999020544015
- Practice claim number
- RHP101212
- Date of service
- Jul 25, 2026
- Rendering provider
- Dr. Samuel Ivers
- Location
- Main Campus
- Payment trace
- GP99900000544, Aug 18, 2026
Line by line, against the contract
| Billed | Paid as | Charged | Contract rate | Allowed | Paid | Shortfall |
|---|---|---|---|---|---|---|
| 97110 | Refused | $140.00 | $68.44 | $0.00 | $0.00 | $68.44 |
| Total | $140.00 | $68.44 | $0.00 | $0.00 | $68.44 | |
Reason and remark codes on the remittance
- CO-16 (adjustment reason), $140.00: Contractual obligation. The claim is missing information or has a billing error. A remark code usually says which field.
- MA130 (remark): The claim was incomplete or invalid and has no appeal rights. Submit a new, corrected claim.
Basis for the request
Read the remark code, fix the field it names, and resubmit.
The practice asks the payer to reprocess this claim at the contracted rate: $68.44 below contract on the lines above.