Claim CLM-2025-9113
Patient
- Name
- Luis Ortega
- Date of birth
- 1991-11-04
- Patient id
- P024
Payer
- Name
- Aetna
- Payer id code
- 60054
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Dec 26 (denial date, no service date on file)
- Procedure
- 71046, Chest X-Ray, 2 Views
- Diagnosis code
- R05.9
- Billed amount
- $769
Denial
- Reason
- Not Covered, code 96
- Date
- Dec 26
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.