Claim CLM-2026-9084
Patient
- Name
- Mateo Fuentes
- Date of birth
- 1951-06-19
- Patient id
- P041
Payer
- Name
- Medicare
- Payer id code
- 00882
Provider
- Name
- Northside Medical
- NPI
- 1982744321
Service
- Date of service
- Jul 29 (denial date, no service date on file)
- Procedure
- 72110, X-Ray Lumbar Spine, 4+ Views
- Diagnosis code
- M54.51
- Billed amount
- $840
Denial
- Reason
- Medical Necessity, code 50
- Date
- Jul 29
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.