SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Nova Commercial
Notice date: 2026-07-22
Claim number: MER-000247
Reference: NOVA-NOT-52ZK60AA

Nova Commercial notice dated 2026-07-22 for claim MER-000247, internal control number NOVA0000247. Adjustment reason CO-11: Diagnosis is inconsistent with the procedure. Remark codes M76, N657. Billed charges 1768.08 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: 31628 at Inpatient hospital

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