CLM-24003

New

Prairie State Medicaid · PT-71059 · Service Oct 22, 2025 · Remit Nov 15, 2025

Billed

$3,094.00

Expected (contract)

$690.20

Paid

$237.80

Variance

$452.40

Win probability

45%

Dispute deadline

Nov 15, 20262d

Root cause: Missing informationNeeds a corrected claim with the missing data elements.Effort: Medium (~40 min)Priority #29 · 7.6

Line items

Underpaid lines are highlighted

Code	Description	Units	Billed	Contracted	Paid	Variance	Adj.
43239	Upper GI endoscopy w/ biopsy	1	$2,028.00	$452.40	$0.00	$452.40	CO-16
74177	CT abdomen & pelvis w/ contrast	1	$1,066.00	$237.80	$237.80	$0.00	CO-45
Claim total			$3,094.00	$690.20	$237.80	$452.40

Evidence

Contract term vs. what the remittance shows

Applicable contract

Prairie State Medicaid

Provider Agreement §12.3 · dispute window 365 days

43239 · Upper GI endoscopy w/ biopsy

Contract: 43239 contracted at $452.40 × 1 unit = $452.40

Remittance: paid $0.00 with CO-16 (Claim lacks information needed for adjudication)

Variance: $452.40 − $0.00 = $452.40

Activity

Nov 15, 2025Remittance received (835)

Dispute letter

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

Nov 13, 2026

Prairie State Medicaid
Attn: Provider Disputes / Claim Reprocessing

RE: Request for reprocessing of underpaid claim CLM-24003
Patient account: PT-71059
Date of service: Oct 22, 2025
Remittance date: Nov 15, 2025

To whom it may concern:

We are writing to formally dispute the payment issued on the claim referenced above. Under our agreement with Prairie State Medicaid, Provider Agreement §12.3, this claim is to be reimbursed at the contracted terms.

Payment summary:
  Contracted (expected) amount: $690.20
  Amount paid:                  $237.80
  Underpayment:                 $452.40

Line-level detail:
  - 43239 Upper GI endoscopy w/ biopsy (1 unit)
    Billed $2,028.00; contracted $452.40 per the contracted fee schedule rate; paid $0.00; variance $452.40.
    Adjustment reason code applied: CO-16 (Claim lacks information needed for adjudication).

Requested action:
Please reprocess claim CLM-24003 at the contracted rate and remit the outstanding balance of $452.40. This dispute is submitted within the 365-day dispute window set out in Provider Agreement §12.3 (deadline Nov 15, 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.