Claim CLM-2026-9063
Patient
- Name
- Mateo Fuentes
- Date of birth
- 1999-02-05
- Patient id
- P037
Payer
- Name
- Cigna
- Payer id code
- 62308
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Jul 12 (denial date, no service date on file)
- Procedure
- 72110, X-Ray Lumbar Spine, 4+ Views
- Diagnosis code
- M54.51
- Billed amount
- $1,429
Denial
- Reason
- Not Covered, code 96
- Date
- Jul 12
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.