Claim CLM-2026-9000

Patient

Name: Rosa Delgado
Date of birth: 1966-08-14
Patient id: P025

Payer

Name: Cigna
Payer id code: 62308

Provider

Name: Northside Medical
NPI: 1982744321

Service

Date of service: Mar 17 (denial date, no service date on file)
Procedure: 72148, MRI Lumbar Spine w/o Contrast
Diagnosis code: M51.16
Billed amount: $5,495

Denial

Reason: Pre-Auth Missing, code 197
Date: Mar 17

Appeal

Status: No appeal filed yet

Prepared by Heron on Aug 30.