| Field | Value |
|---|---|
| Patient Name | WOODROW KIBBY |
| Date of Birth | 4848-26 |
| Date(s) of Service | 04/28/2026 |
| Claim Number | 4848 |
| Origin City | 8401 FOUNTAIN AVENUE Blg 1 WEST HOLLYWOOD, CA 90069-2561 US |
| Destination | Blg 3 EAST HOLLYWOOD, CA 90069-2561 US |
| Emergency? | Yes |
| Hospital Ordered? | Yes |
| Transport Type | CCT |
| Transport Context | SNF → Hospital |
| PAYER TYPE | Medi-Cal |
| DENIAL TYPE | Underpayment |
| ESCALATION LEVEL | Second Appeal |
| Optional Flag | Include Interest Demand |
Print Appeal | Edit Entry