| Field | Value |
|---|---|
| Appeal Category: | Call The Car |
| Appeal Type Name: | HN MODS |
| Payor Name: | LA Care Health Plan |
| Payor Address: | P.O. Box 811610 Los Angeles, CA 90081 |
| Payor Type: | CA HMO (Knox-Keene) |
| Department: | Attn: Grievance and Appeals Resolution Services |
| Full Name: | Enrique Hernandez |
| Date of Birth: | 02/03/2026 |
| Internal PDR#: | 12345678F |
| Claim Number: | 10-26 |
| Date(s) of Service: | 06/11/2026 |
| Member ID: | 984881981XX93 |
| Status: | Pending |
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