Mercy Valley Regional · Patient Financial Services
Demo dataCLM-24033
NewPrairie State Medicaid · PT-36356 · Service Nov 2, 2025 · Remit Nov 19, 2025
Billed
$10,166.00
Expected (contract)
$2,267.80
Paid
$1,194.80
Variance
$1,073.00
Win probability
45%
Dispute deadline
Nov 19, 20266d
Root cause: Missing informationNeeds a corrected claim with the missing data elements.Effort: Medium (~40 min)Priority #20 · 18.1
Line items
Underpaid lines are highlighted
| Code | Description | Units | Billed | Contracted | Paid | Variance | Adj. |
|---|---|---|---|---|---|---|---|
| 29881 | Knee arthroscopy, meniscectomy | 1 | $4,810.00 | $1,073.00 | $0.00 | $1,073.00 | CO-16 |
| 66984 | Cataract removal w/ IOL | 1 | $3,692.00 | $823.60 | $823.60 | $0.00 | CO-45 |
| 70553 | MRI brain w/o & w/ contrast | 1 | $1,664.00 | $371.20 | $371.20 | $0.00 | CO-45 |
| Claim total | $10,166.00 | $2,267.80 | $1,194.80 | $1,073.00 | |||
Evidence
Contract term vs. what the remittance shows
Applicable contract
Prairie State Medicaid
Provider Agreement §12.3 · dispute window 365 days
29881 · Knee arthroscopy, meniscectomy
Contract: 29881 contracted at $1,073.00 × 1 unit = $1,073.00
Remittance: paid $0.00 with CO-16 (Claim lacks information needed for adjudication)
Variance: $1,073.00 − $0.00 = $1,073.00
Activity
- Nov 19, 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-24033
Patient account: PT-36356
Date of service: Nov 2, 2025
Remittance date: Nov 19, 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: $2,267.80
Amount paid: $1,194.80
Underpayment: $1,073.00
Line-level detail:
- 29881 Knee arthroscopy, meniscectomy (1 unit)
Billed $4,810.00; contracted $1,073.00 per the contracted fee schedule rate; paid $0.00; variance $1,073.00.
Adjustment reason code applied: CO-16 (Claim lacks information needed for adjudication).
Requested action:
Please reprocess claim CLM-24033 at the contracted rate and remit the outstanding balance of $1,073.00. This dispute is submitted within the 365-day dispute window set out in Provider Agreement §12.3 (deadline Nov 19, 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.