SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Summit Advantage Dual
Notice date: 2025-12-11
Claim number: MER-000601
Reference: SUMMIT-NOT-NMZNWGBY

Summit Advantage Dual notice dated 2025-12-11 for claim MER-000601, internal control number SUMMIT0000601. Adjustment reason CO-50: Not deemed a medical necessity by the payer. Remark codes N115, M127. Billed charges 1773.78 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: 77385 at Office

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