SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Atlas Health
Notice date: 2026-06-22
Claim number: MER-000505
Reference: ATLAS-NOT-JH12DRY3

Atlas Health notice dated 2026-06-22 for claim MER-000505, internal control number ATLAS0000505. Adjustment reason CO-16: Claim or service lacks information or has submission or billing errors. No remark code was supplied with this adjustment. Billed charges 19067.50 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: 49505 at Ambulatory surgical center

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