Claim CLM-2025-9052
Patient
- Name
- Ingrid Solberg
- Date of birth
- 2002-03-01
- Patient id
- P021
Payer
- Name
- Aetna
- Payer id code
- 60054
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Dec 19 (denial date, no service date on file)
- Procedure
- 96415, Chemotherapy Infusion, Addl Hour
- Diagnosis code
- C34.90
- Billed amount
- $16,925
Denial
- Reason
- Pre-Auth Missing, code 197
- Date
- Dec 19
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.