Claim CLM-2026-9043

Patient

Name: Rosa Delgado
Date of birth: 1966-08-14
Patient id: P025

Payer

Name: Cigna
Payer id code: 62308

Provider

Name: Northside Medical
NPI: 1982744321

Service

Date of service: Jan 28 (denial date, no service date on file)
Procedure: 97140, Manual Therapy, 15 min
Diagnosis code: M54.2
Billed amount: $1,335

Denial

Reason: Medical Necessity, code 50
Date: Jan 28

Appeal

Status: No appeal filed yet

Prepared by Heron on Aug 30.