Claim CLM-2026-9093
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
- Aug 10 (denial date, no service date on file)
- Procedure
- 70553, MRI Brain w/ and w/o Contrast
- Diagnosis code
- G43.909
- Billed amount
- $2,542
Denial
- Reason
- Pre-Auth Missing, code 197
- Date
- Aug 10
Appeal
- Status
- No appeal filed yet
Prepared by Heron on Aug 30.