Claim CLM-G0117165
$333.14
billed
$288.67
allowed
$0.00
paid
$0.00
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Complete blood count | 85025 | $29.30 | $0.00 |
| Preventive visit, established patient | 99396 | $163.07 | $0.00 |
| Office visit, established patient, level 3 | 99213 | $140.77 | $0.00 |
Denial risk — 10/99
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 |
|---|---|
| Blue Cross Blue Shield denial history: 888 of 8634 claims denied (10%) | -0.16 |
| Service 99396 (Preventive visit, established patient): 666 of 5902 historically denied (11%) | -0.01 |