Mercy Valley Regional · Patient Financial Services

CLM-24001

New

Unity Benefit Administrators (TPA) · on behalf of Northlake Health Plan · PT-67451 · Service Sep 5, 2026 · Remit Sep 26, 2026

Billed

$200,000.00

Expected (contract)

$150,000.00

Paid

$110,000.00

Variance

$40,000.00

Win probability

80%

Dispute deadline

Nov 25, 202612d

Root cause: Percent-of-charges errorArithmetic is verifiable from billed charges and the contract percentage.Effort: Medium (~40 min)Priority #1 · 1200.0

Line items

Underpaid lines are highlighted

Code	Description	Units	Billed	Contracted	Paid	Variance	Adj.
0120	Room & board, semi-private (6 days)	1	$92,000.00	$69,000.00	$50,600.00	$18,400.00	CO-45
0360	Operating room services	1	$64,000.00	$48,000.00	$35,200.00	$12,800.00	CO-45
0278	Implants (total knee system)	1	$30,000.00	$22,500.00	$16,500.00	$6,000.00	CO-45
0250	Pharmacy	1	$14,000.00	$10,500.00	$7,700.00	$2,800.00	CO-45
Claim total			$200,000.00	$150,000.00	$110,000.00	$40,000.00

Evidence

Contract term vs. what the remittance shows

Applicable contract

Northlake Health Plan network agreement

Section 4.2, Exhibit B · dispute window 60 days

Unity Benefit Administrators (TPA) is a TPA administering this claim under the Northlake Health Plan network contract.

Inpatient: 75% of billed charges

0120 · Room & board, semi-private (6 days)

Contract: $92,000.00 billed × 75% of charges = $69,000.00

Remittance: paid $50,600.00 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $69,000.00 − $50,600.00 = $18,400.00

0360 · Operating room services

Contract: $64,000.00 billed × 75% of charges = $48,000.00

Remittance: paid $35,200.00 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $48,000.00 − $35,200.00 = $12,800.00

0278 · Implants (total knee system)

Contract: $30,000.00 billed × 75% of charges = $22,500.00

Remittance: paid $16,500.00 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $22,500.00 − $16,500.00 = $6,000.00

0250 · Pharmacy

Contract: $14,000.00 billed × 75% of charges = $10,500.00

Remittance: paid $7,700.00 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $10,500.00 − $7,700.00 = $2,800.00

Total: $150,000.00 − $110,000.00 = $40,000.00

Activity

Sep 26, 2026Remittance received (835)

Dispute letter

Generated from this claim's data only. Review before sending.

Nov 13, 2026

Unity Benefit Administrators (TPA)
Attn: Provider Disputes / Claim Reprocessing

RE: Request for reprocessing of underpaid claim CLM-24001
Patient account: PT-67451
Date of service: Sep 5, 2026
Remittance date: Sep 26, 2026

To whom it may concern:

We are writing to formally dispute the payment issued on the claim referenced above. Under the Northlake Health Plan network agreement, Section 4.2, Exhibit B, this claim is to be reimbursed at the contracted terms. Unity Benefit Administrators (TPA) administers this claim on behalf of the Northlake Health Plan network and is bound by that agreement's reimbursement terms.

Payment summary:
  Contracted (expected) amount: $150,000.00
  Amount paid:                  $110,000.00
  Underpayment:                 $40,000.00

Line-level detail:
  - 0120 Room & board, semi-private (6 days) (1 unit)
    Billed $92,000.00; contracted $69,000.00 per 75% of billed charges; paid $50,600.00; variance $18,400.00.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
  - 0360 Operating room services (1 unit)
    Billed $64,000.00; contracted $48,000.00 per 75% of billed charges; paid $35,200.00; variance $12,800.00.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
  - 0278 Implants (total knee system) (1 unit)
    Billed $30,000.00; contracted $22,500.00 per 75% of billed charges; paid $16,500.00; variance $6,000.00.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
  - 0250 Pharmacy (1 unit)
    Billed $14,000.00; contracted $10,500.00 per 75% of billed charges; paid $7,700.00; variance $2,800.00.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).

Requested action:
Please reprocess claim CLM-24001 at the contracted rate and remit the outstanding balance of $40,000.00. This dispute is submitted within the 60-day dispute window set out in Section 4.2, Exhibit B (deadline Nov 25, 2026). We request a reprocessed remittance or written determination within the timeframe specified by that section.

Sincerely,

[Reviewer name]
Revenue Cycle / Patient Financial Services
[Hospital name]

Requires reviewer confirmation.