Mercy Valley Regional · Patient Financial Services
Demo dataCLM-24009
NewCrestline TPA Services · on behalf of Meridian Mutual · PT-21146 · Service Aug 23, 2026 · Remit Oct 2, 2026
Billed
$8,502.00
Expected (contract)
$3,531.60
Paid
$1,533.60
Variance
$1,998.00
Win probability
65%
Dispute deadline
Nov 16, 20263d
Root cause: Duplicate in errorRequires showing the services were distinct encounters.Effort: Medium (~40 min)Priority #9 · 48.7
Line items
Underpaid lines are highlighted
| Code | Description | Units | Billed | Contracted | Paid | Variance | Adj. |
|---|---|---|---|---|---|---|---|
| 29881 | Knee arthroscopy, meniscectomy | 1 | $4,810.00 | $1,998.00 | $0.00 | $1,998.00 | CO-18 |
| 66984 | Cataract removal w/ IOL | 1 | $3,692.00 | $1,533.60 | $1,533.60 | $0.00 | CO-45 |
| Claim total | $8,502.00 | $3,531.60 | $1,533.60 | $1,998.00 | |||
Evidence
Contract term vs. what the remittance shows
Applicable contract
Meridian Mutual network agreement
Article 6.1, Schedule A · dispute window 45 days
Crestline TPA Services is a TPA administering this claim under the Meridian Mutual network contract.
Inpatient: 72% of billed charges
29881 · Knee arthroscopy, meniscectomy
Contract: 29881 contracted at $1,998.00 × 1 unit = $1,998.00
Remittance: paid $0.00 with CO-18 (Exact duplicate claim/service)
Variance: $1,998.00 − $0.00 = $1,998.00
Activity
- Oct 2, 2026Remittance received (835)
Dispute letter
Generated from this claim's data only. Review before sending.
Nov 13, 2026
Crestline TPA Services
Attn: Provider Disputes / Claim Reprocessing
RE: Request for reprocessing of underpaid claim CLM-24009
Patient account: PT-21146
Date of service: Aug 23, 2026
Remittance date: Oct 2, 2026
To whom it may concern:
We are writing to formally dispute the payment issued on the claim referenced above. Under the Meridian Mutual network agreement, Article 6.1, Schedule A, this claim is to be reimbursed at the contracted terms. Crestline TPA Services administers this claim on behalf of the Meridian Mutual network and is bound by that agreement's reimbursement terms.
Payment summary:
Contracted (expected) amount: $3,531.60
Amount paid: $1,533.60
Underpayment: $1,998.00
Line-level detail:
- 29881 Knee arthroscopy, meniscectomy (1 unit)
Billed $4,810.00; contracted $1,998.00 per the contracted fee schedule rate; paid $0.00; variance $1,998.00.
Adjustment reason code applied: CO-18 (Exact duplicate claim/service).
Requested action:
Please reprocess claim CLM-24009 at the contracted rate and remit the outstanding balance of $1,998.00. This dispute is submitted within the 45-day dispute window set out in Article 6.1, Schedule A (deadline Nov 16, 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.