Claim CLM-2026-9041

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: Jun 22 (denial date, no service date on file)
Procedure: 96413, Chemotherapy Infusion, 1st Hour
Diagnosis code: C50.911
Billed amount: $14,703

Denial

Reason: Medical Necessity, code 50
Date: Jun 22

Appeal

Status: No appeal filed yet

Prepared by Heron on Aug 30.