CLM-24051

New

Crestline TPA Services · on behalf of Meridian Mutual · PT-33569 · Service Sep 13, 2026 · Remit Oct 5, 2026

Billed

$4,810.00

Expected (contract)

$1,998.00

Paid

$1,476.08

Variance

$521.92

Win probability

85%

Dispute deadline

Nov 19, 20266d

Root cause: Wrong fee scheduleContracted rate is explicit; the TPA priced against a non-network schedule.Effort: Low (~15 min)Priority #11 · 44.4

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	$1,476.08	$521.92	CO-45
Claim total			$4,810.00	$1,998.00	$1,476.08	$521.92

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 $1,476.08 with CO-45 (Charge exceeds fee schedule / contractual adjustment)

Variance: $1,998.00 − $1,476.08 = $521.92

Activity

Oct 5, 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-24051
Patient account: PT-33569
Date of service: Sep 13, 2026
Remittance date: Oct 5, 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: $1,998.00
  Amount paid:                  $1,476.08
  Underpayment:                 $521.92

Line-level detail:
  - 29881 Knee arthroscopy, meniscectomy (1 unit)
    Billed $4,810.00; contracted $1,998.00 per the contracted fee schedule rate; paid $1,476.08; variance $521.92.
    Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).

Requested action:
Please reprocess claim CLM-24051 at the contracted rate and remit the outstanding balance of $521.92. This dispute is submitted within the 45-day dispute window set out in Article 6.1, Schedule A (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.