Caleb Nguyen

CLM-2026-9077, Medicare, Therapeutic Activities, 15 min (97530)

DeniedWith me Denied claims

Billed

$350

denied Aug 23

Denial risk

82%

a hard one, worth it

Appeal window

83d

closes Nov 21

Appeals

none filed yet

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Aug 23
Denied by Medicare
Pre-Auth Missing (197)
Aug 23
Heron scored it: 82% denial risk
3 factors found, appeal path chosen
Aug 23
Appeal window closes
83 days left to file
Nov 21

The denial

Pre-Auth Missing, code 197

Patient: Caleb Nguyen, born 1950-12-12
Payer: Medicare
Procedure: Therapeutic Activities, 15 min (97530)
Diagnosis: M62.81
Denied on: Aug 23, 2026
Assigned to: Heron

Heron says

High recovery risk (82), prioritize this claim in the appeal queue. Prior authorization was not on file at time of service, Medicare auto-denies 97530 without it. 6 similar denials at this facility in the last 90 days for the same reason.

No appeal yet

I can draft one from this claim's history

Draft it View the claim form

Open Intelligence, pick this claim, and I write the letter from the denial, the payer's rules and the clinical guideline. You sign it here.

What I sent

Referral on file

Everything I know about Caleb

across every queue

Everything for this patient

Open exposure

$15,454

Recovered

$2,295

2 denied claims1 prior auth3 underpayments3 backlog claims

CLM-2026-9077viewing

97530 · Pre-Auth Missing

96415 · 10d outstanding

71046 · 32d outstanding

96415 · Chemotherapy Infusion, Addl Hour

73630 · 55d outstanding

97530 · Duplicate Claim

73630 · underpaid 30.5%

96413 · underpaid 15.5%

96415 · underpaid 27%

$579 short

Recovered

Sep 30