CLM-24045

New

Crestline TPA Services · on behalf of Meridian Mutual · PT-40434 · Service Sep 16, 2026 · Remit Oct 9, 2026

Billed

$65,936.00

Expected (contract)

$47,473.92

Paid

$41,973.89

Variance

$5,500.03

Win probability

80%

Dispute deadline

Nov 23, 202610d

Root cause: Percent-of-charges errorArithmetic is verifiable from billed charges and the contract percentage.Effort: Medium (~40 min)Priority #3 · 165.0

Line items

Underpaid lines are highlighted

Code	Description	Units	Billed	Contracted	Paid	Variance	Adj.
0120	Room & board	1	$16,765.00	$12,070.80	$10,433.12	$1,637.68	CO-45
0360	Operating room services	1	$12,307.00	$8,861.04	$7,883.34	$977.70	CO-45
0250	Pharmacy	1	$19,805.00	$14,259.60	$12,559.30	$1,700.30	CO-45
0300	Laboratory	1	$17,059.00	$12,282.48	$11,098.13	$1,184.35	CO-45
Claim total			$65,936.00	$47,473.92	$41,973.89	$5,500.03

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

0120 · Room & board

Contract: $16,765.00 billed × 72% of charges = $12,070.80

Remittance: paid $10,433.12 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $12,070.80 − $10,433.12 = $1,637.68

0360 · Operating room services

Contract: $12,307.00 billed × 72% of charges = $8,861.04

Remittance: paid $7,883.34 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $8,861.04 − $7,883.34 = $977.70

0250 · Pharmacy

Contract: $19,805.00 billed × 72% of charges = $14,259.60

Remittance: paid $12,559.30 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $14,259.60 − $12,559.30 = $1,700.30

0300 · Laboratory

Contract: $17,059.00 billed × 72% of charges = $12,282.48

Remittance: paid $11,098.13 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $12,282.48 − $11,098.13 = $1,184.35

Total: $47,473.92 − $41,973.89 = $5,500.03

Activity

Oct 9, 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-24045
Patient account: PT-40434
Date of service: Sep 16, 2026
Remittance date: Oct 9, 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: $47,473.92
  Amount paid:                  $41,973.89
  Underpayment:                 $5,500.03

Line-level detail:
  - 0120 Room & board (1 unit)
    Billed $16,765.00; contracted $12,070.80 per 72% of billed charges; paid $10,433.12; variance $1,637.68.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
  - 0360 Operating room services (1 unit)
    Billed $12,307.00; contracted $8,861.04 per 72% of billed charges; paid $7,883.34; variance $977.70.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
  - 0250 Pharmacy (1 unit)
    Billed $19,805.00; contracted $14,259.60 per 72% of billed charges; paid $12,559.30; variance $1,700.30.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
  - 0300 Laboratory (1 unit)
    Billed $17,059.00; contracted $12,282.48 per 72% of billed charges; paid $11,098.13; variance $1,184.35.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).

Requested action:
Please reprocess claim CLM-24045 at the contracted rate and remit the outstanding balance of $5,500.03. This dispute is submitted within the 45-day dispute window set out in Article 6.1, Schedule A (deadline Nov 23, 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.