Claim CLM-2025-9003
Patient
- Name
- Hannah Kowalczyk
- Date of birth
- 1955-05-10
- Patient id
- P022
Payer
- Name
- Medicare
- Payer id code
- 00882
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Dec 30 (denial date, no service date on file)
- Procedure
- 70553, MRI Brain w/ and w/o Contrast
- Diagnosis code
- G43.909
- Billed amount
- $5,035
Denial
- Reason
- Pre-Auth Missing, code 197
- Date
- Dec 30
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.