Mercy Valley Regional · Patient Financial Services
Demo dataCLM-24039
NewNorthlake Health Plan · PT-82275 · Service Jul 14, 2026 · Remit Aug 24, 2026
Billed
$9,243.00
Expected (contract)
$3,555.00
Paid
$2,630.00
Variance
$925.00
Win probability
75%
Dispute deadline
Nov 22, 20269d
Root cause: Modifier ignoredContract defines modifier 50 (bilateral) pricing at 150%.Effort: Low (~15 min)Priority #6 · 69.4
Line items
Underpaid lines are highlighted
| Code | Description | Units | Billed | Contracted | Paid | Variance | Adj. |
|---|---|---|---|---|---|---|---|
| 29881-50 | Knee arthroscopy, meniscectomy | 1 | $7,215.00 | $2,775.00 | $1,850.00 | $925.00 | CO-45 |
| 43239 | Upper GI endoscopy w/ biopsy | 1 | $2,028.00 | $780.00 | $780.00 | $0.00 | CO-45 |
| Claim total | $9,243.00 | $3,555.00 | $2,630.00 | $925.00 | |||
Evidence
Contract term vs. what the remittance shows
Applicable contract
Northlake Health Plan
Section 4.2, Exhibit B · dispute window 90 days
Inpatient: 75% of billed charges
29881-50 · Knee arthroscopy, meniscectomy
Contract: 29881 contracted at $1,850.00 × 1 unit × 150% (modifier 50) = $2,775.00
Remittance: paid $1,850.00 with CO-45 (Charge exceeds fee schedule / contractual adjustment)
Variance: $2,775.00 − $1,850.00 = $925.00
Activity
- Aug 24, 2026Remittance received (835)
Dispute letter
Generated from this claim's data only. Review before sending.
Nov 13, 2026
Northlake Health Plan
Attn: Provider Disputes / Claim Reprocessing
RE: Request for reprocessing of underpaid claim CLM-24039
Patient account: PT-82275
Date of service: Jul 14, 2026
Remittance date: Aug 24, 2026
To whom it may concern:
We are writing to formally dispute the payment issued on the claim referenced above. Under our agreement with Northlake Health Plan, Section 4.2, Exhibit B, this claim is to be reimbursed at the contracted terms.
Payment summary:
Contracted (expected) amount: $3,555.00
Amount paid: $2,630.00
Underpayment: $925.00
Line-level detail:
- 29881-50 Knee arthroscopy, meniscectomy (1 unit)
Billed $7,215.00; contracted $2,775.00 per the contracted fee schedule rate; paid $1,850.00; variance $925.00.
Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
Requested action:
Please reprocess claim CLM-24039 at the contracted rate and remit the outstanding balance of $925.00. This dispute is submitted within the 90-day dispute window set out in Section 4.2, Exhibit B (deadline Nov 22, 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.