SYNTHETIC PAYER CORRESPONDENCE. NO PAYER HAS ISSUED THIS NOTICE.
Atlas Health
Notice date: 2026-08-20
Claim number: MER-000647
Reference: ATLAS-NOT-783D97FP

Atlas Health notice dated 2026-08-20 for claim MER-000647, internal control number ATLAS0000647. Adjustment reason CO-96: Non covered charges. Remark codes N130, N180. Billed charges 26273.37 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: J9035 at On campus outpatient hospital

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