SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Traditional Medicare
Notice date: 2026-08-02
Claim number: MER-000269
Reference: MEDICARE-NOT-38GYC2JL

Traditional Medicare notice dated 2026-08-02 for claim MER-000269, internal control number MEDICARE0000269. Adjustment reason CO-96: Non covered charges. Remark codes N180, N130. Billed charges 13228.28 USD. No payment was issued for this claim. 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: 49650 at Ambulatory surgical center

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