SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Harbor Assurance
Notice date: 2026-09-06
Claim number: MER-000192
Reference: HARBOR-NOT-QJPH46TF

Harbor Assurance notice dated 2026-09-06 for claim MER-000192, internal control number HARBOR0000192. Adjustment reason CO-197: Precertification, authorization, notification or pre-treatment absent. Remark codes N10, M62. Billed charges 861.45 USD. A partial payment was issued and the balance of the service was denied. Appeal rights are described in the provider manual applicable to the plan; the window is recorded in the fee schedule exhibit for this payer. Synthetic correspondence; no payer has issued this notice.

HOW TO READ THIS NOTICE
The adjustment reason code and any remark codes describe the payer decision. They do not state
a denial family, an expected allowed amount, a recovery probability or a filing deadline. Those
are derived by joining this notice to the remittance, the fee schedule exhibit and the payer
profile. Notices are presumed received five days after their date.

Place of service on the claim: 94729 at On campus outpatient hospital

All payer names, references, amounts and rules in this document are fictional.
