Claim CLM-2026-9079
Patient
- Name
- Oscar Lindqvist
- Date of birth
- 1995-12-13
- Patient id
- P047
Payer
- Name
- Aetna
- Payer id code
- 60054
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- May 4 (denial date, no service date on file)
- Procedure
- 73630, X-Ray Foot, Complete
- Diagnosis code
- M79.671
- Billed amount
- $1,285
Denial
- Reason
- Pre-Auth Missing, code 197
- Date
- May 4
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.