| Field | Value |
|---|---|
| Patient Name | Robert S. Rankel |
| Date of Birth | 48-25 |
| Date(s) of Service | 01/01/2025 |
| Claim Number | 157456 |
| Origin City | LA Community Hospital 4081 E Olympic Blvd Los Angeles, CA 90023-0000 US |
| Destination | LA COMMUNITY HOSPITAL - BELLFLOWER 9542 ARTESIA BLVD BELLFLOWER, CA 90706 US |
| Emergency? | Yes |
| Hospital Ordered? | Yes |
| Transport Type | BLS |
| Transport Context | ER → Hospital |
| PAYER TYPE | CA HMO (Knox-Keene) |
| DENIAL TYPE | No Claim on File |
| ESCALATION LEVEL | First Appeal |
| Optional Flag | Include Interest Demand |
Print Appeal | Edit Entry