| Field | Value |
|---|---|
| Patient Name | John Christian Smith |
| Date of Birth | 12345-26 |
| Date(s) of Service | 05/09/2026 |
| Claim Number | 55555 |
| Origin City | 8401 FOUNTAIN AVENUE WEST HOLLYWOOD, CA 90069-2561 US |
| Destination | 8401 FOUNTAIN AVENUE WEST HOLLYWOOD, CA 90069-2561 US |
| Emergency? | Yes |
| Hospital Ordered? | Yes |
| Transport Type | BLS |
| Transport Context | ER → Hospital |
| PAYER TYPE | Medicare |
| DENIAL TYPE | Timely Filing |
| ESCALATION LEVEL | First Appeal |
| Optional Flag | Prior Appeal Submitted |
Print Appeal | Edit Entry