SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Harbor Assurance
Notice date: 2026-07-31
Claim number: MER-000287
Reference: HARBOR-NOT-E5NDL7J4

Harbor Assurance notice dated 2026-07-31 for claim MER-000287, internal control number HARBOR0000287. Adjustment reason CO-97: Benefit for this service is included in the payment of another service. Remark codes N390. Billed charges 81278.77 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: 44204 at Inpatient hospital

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