Claim CLM-2025-9004
Patient
- Name
- Tomas Herrera
- Date of birth
- 1968-02-27
- Patient id
- P014
Payer
- Name
- UnitedHealthcare
- Payer id code
- 87726
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Dec 4 (denial date, no service date on file)
- Procedure
- 96417, Chemotherapy, Additional Sequential
- Diagnosis code
- C18.9
- Billed amount
- $12,770
Denial
- Reason
- Medical Necessity, code 50
- Date
- Dec 4
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.