| Field | Value |
|---|---|
| Appeal Category: | QAF |
| Payor Name: | Aetna Medi-Cal |
| Payor Address: | P.O. Box 14020 Lexington, KY 40512-4079 |
| Payor Type: | Original Payor |
| Department: | Attn: Grievance and Appeals Resolution Services |
| Full Name: | Nicholas Allen |
| Date of Birth: | 03/09/1981 |
| Internal PDR#: | MID442356 |
| Claim Number: | PDR10250 |
| Date(s) of Service: | 06/28/2026 |
| Member ID: | CLM900140 |
| Status: | Paid |
| Entered by: | Francis Paul Alojipan |
| Field 64 | HealthNet |
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