Date: June 13, 2026 3:42 PM

Member Name:
Member DOB:
Claim Number:
Internal PDR:

DENIAL LOOP

Dear Director of Claims/Utilization Review,

This letter serves as a formal appeal regarding the underpayment of ambulance services rendered to the above-named member.

Our records confirm that FirstMed Ambulance Services is a contracted provider with to 28 CCR §1300.71(a)(3)(A), contracted providers must be reimbursed at the agreed-upon contracted rate.

As you know, an established contract exists between FirstMed Ambulance and , with the following agreed rates as set forth in the Ancillary Services Compensation Schedule (see attached):

• A0426 – ADVANCED LIFE SUPPORT (ALS): $400.00
• A0427 – ALS EMERGENCY: $400.00
• A0428 – BASIC LIFE SUPPORT (BLS): $270.00
• A0429 – BLS EMERGENCY: $270.00
• A0434 – CRITICAL CARE TRANSPORT (CCT): $1,000.00
• A0425 – MILEAGE (per mile): $7.85
• A0420 – WAIT TIME (per 15 min after 30 min): $40.00

Despite these clearly established rates, has only reimbursed this claim in the amount of $[Paid Amount], resulting in an Underpayment of $[Underpaid Amount]. This failure to adhere to the contracted fee schedule is a violation of both the contract and California law.

We hereby demand immediate payment of the underpaid balance, plus any applicable interest pursuant to 28 CCR §1300.71(i). Should payment not be remitted within ten (10) business days, please be advised that we are prepared to escalate this matter to the Department of Managed Health Care (DMHC) for enforcement action.

Please make further action unnecessary by issuing corrected payment in full at your earliest opportunity.

Respectfully,
 
 
 

Kristina Bableyan
CEO / Senior Billing Compliance Coordinator
Firstmed Ambulance Services, Inc.
Phone: (818)230-1600 x301
Email: kbableyan@firstmedambulance.com