Mercy Valley Regional · Patient Financial Services
Demo dataCLM-24057
NewUnity Benefit Administrators (TPA) · on behalf of Northlake Health Plan · PT-72378 · Service Aug 21, 2026 · Remit Sep 18, 2026
Billed
$3,692.00
Expected (contract)
$1,420.00
Paid
$1,102.44
Variance
$317.56
Win probability
85%
Dispute deadline
Nov 17, 20264d
Root cause: Wrong fee scheduleContracted rate is explicit; the TPA priced against a non-network schedule.Effort: Low (~15 min)Priority #13 · 27.0
Line items
Underpaid lines are highlighted
| Code | Description | Units | Billed | Contracted | Paid | Variance | Adj. |
|---|---|---|---|---|---|---|---|
| 70553 | MRI brain w/o & w/ contrast | 1 | $1,664.00 | $640.00 | $514.43 | $125.57 | CO-45 |
| 43239 | Upper GI endoscopy w/ biopsy | 1 | $2,028.00 | $780.00 | $588.01 | $191.99 | CO-45 |
| Claim total | $3,692.00 | $1,420.00 | $1,102.44 | $317.56 | |||
Evidence
Contract term vs. what the remittance shows
Applicable contract
Northlake Health Plan network agreement
Section 4.2, Exhibit B · dispute window 60 days
Unity Benefit Administrators (TPA) is a TPA administering this claim under the Northlake Health Plan network contract.
Inpatient: 75% of billed charges
70553 · MRI brain w/o & w/ contrast
Contract: 70553 contracted at $640.00 × 1 unit = $640.00
Remittance: paid $514.43 with CO-45 (Charge exceeds fee schedule / contractual adjustment)
Variance: $640.00 − $514.43 = $125.57
43239 · Upper GI endoscopy w/ biopsy
Contract: 43239 contracted at $780.00 × 1 unit = $780.00
Remittance: paid $588.01 with CO-45 (Charge exceeds fee schedule / contractual adjustment)
Variance: $780.00 − $588.01 = $191.99
Total: $1,420.00 − $1,102.44 = $317.56
Activity
- Sep 18, 2026Remittance received (835)
Dispute letter
Generated from this claim's data only. Review before sending.
Nov 13, 2026
Unity Benefit Administrators (TPA)
Attn: Provider Disputes / Claim Reprocessing
RE: Request for reprocessing of underpaid claim CLM-24057
Patient account: PT-72378
Date of service: Aug 21, 2026
Remittance date: Sep 18, 2026
To whom it may concern:
We are writing to formally dispute the payment issued on the claim referenced above. Under the Northlake Health Plan network agreement, Section 4.2, Exhibit B, this claim is to be reimbursed at the contracted terms. Unity Benefit Administrators (TPA) administers this claim on behalf of the Northlake Health Plan network and is bound by that agreement's reimbursement terms.
Payment summary:
Contracted (expected) amount: $1,420.00
Amount paid: $1,102.44
Underpayment: $317.56
Line-level detail:
- 70553 MRI brain w/o & w/ contrast (1 unit)
Billed $1,664.00; contracted $640.00 per the contracted fee schedule rate; paid $514.43; variance $125.57.
Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
- 43239 Upper GI endoscopy w/ biopsy (1 unit)
Billed $2,028.00; contracted $780.00 per the contracted fee schedule rate; paid $588.01; variance $191.99.
Adjustment reason code applied: CO-45 (Charge exceeds fee schedule / contractual adjustment).
Requested action:
Please reprocess claim CLM-24057 at the contracted rate and remit the outstanding balance of $317.56. This dispute is submitted within the 60-day dispute window set out in Section 4.2, Exhibit B (deadline Nov 17, 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.