Claim CLM-2026146007
$737.28
billed
$516.10
allowed
$0.00
paid
$0.00
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| {21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Levora 0.15/30 28 Day] | 748879 | $0.00 | $0.00 |
Denial risk — 8/99
Scored by the denial-risk model before adjudication. Advisory only — nothing blocks on a score; the factors below cite the adjudication history they came from.
| Factor | Weight |
|---|---|
| Humana denial history: 331 of 4047 claims denied (8%) | -0.12 |