Claim CLM-2026-9035
Patient
- Name
- Keiko Mori
- Date of birth
- 1972-11-26
- Patient id
- P049
Payer
- Name
- Medicaid
- Payer id code
- 77043
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Apr 27 (denial date, no service date on file)
- Procedure
- 96417, Chemotherapy, Additional Sequential
- Diagnosis code
- C18.9
- Billed amount
- $11,136
Denial
- Reason
- Medical Necessity, code 50
- Date
- Apr 27
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.