| Field | Value |
|---|---|
| Patient Name | Joshua Delos Reyes |
| Date(s) of Service | 04/23/2026 |
| Claim Number | 7657658765876 |
| Emergency? | Yes |
| Hospital Ordered? | Yes |
| Transport Type | ALS |
| Transport Context | Dialysis |
| PAYER TYPE | CA HMO (Knox-Keene) |
| DENIAL TYPE | Underpayment |
| ESCALATION LEVEL | Second Appeal |
| Optional Flag | Prior Appeal Submitted |
Print Appeal | Edit Entry