Heron

Paloma Reyes

CLM-2026-9124, Aetna, Therapeutic Exercise, 15 min (97110)

In appealWith the payer Denied claims
Billed
$410
denied Jan 29
Denial risk
87%
a hard one, worth it
Appeal window
lapsed
closes Apr 29
Appeals
0
none filed yet

What I did

and what comes next
  1. Claim reached Heron
    Entered by hand
    Jan 29
  2. Denied by Aetna
    Pre-Auth Missing (197)
    Jan 29
  3. Heron
    Heron scored it: 87% denial risk
    3 factors found, appeal path chosen
    Jan 29

The denial

Pre-Auth Missing, code 197

Patient
Paloma Reyes, born 1990-03-28
Payer
Aetna
Procedure
Therapeutic Exercise, 15 min (97110)
Diagnosis
M25.561
Denied on
Jan 29, 2026
Assigned to
Heron
Heron says
High recovery risk (87), prioritize this claim in the appeal queue. Prior authorization was not on file at time of service, Aetna auto-denies 97110 without it. 4 similar denials at this facility in the last 90 days for the same reason.

No appeal yet

I can draft one from this claim's history

Draft itView the claim form

Open Intelligence, pick this claim, and I write the letter from the denial, the payer's rules and the clinical guideline. You sign it here.

What I sent

  • Referral on file

Everything I know about Paloma

across every queue
Everything for this patient
Open exposure
$50,201
Recovered
$0
3 denied claims2 prior auths1 underpayment3 backlog claims
AUTH-4053
96417 · Chemotherapy, Additional Sequential
92% odds
Pending
Aug 28
AUTH-4058
96415 · Chemotherapy Infusion, Addl Hour
44% odds
Approved
Aug 24
CLM-2026-5043
96417 · 6d outstanding
$12,951
Pending payer
Aug 24
CLM-2026-5083
96415 · 8d outstanding
$10,613
In follow up
Aug 22
CLM-2026-9102
96415 · Bundling/Coding Error
$13,501
Denied
Aug 19
CLM-2026-5137
96417 · 18d outstanding
$9,547
Pending payer
Aug 12
CLM-2026-9044
96415 · Missing Information
$3,108
Denied
Jun 21
CLM-2026-7038
97530 · underpaid 19.7%
$71 short
Under review
Jun 13
CLM-2026-9124viewing
97110 · Pre-Auth Missing
$410
In appeal
Jan 29