CLM-2026-000213
Riverside Primary Care Associates, Family Medicine. Service 2026-05-01 at office (POS 11). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Alexis Watkins
- Member ID
- UHC-25813-01
- Date of birth
- 1946-10-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412467
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2480
- Coverage period
- 2024-05-01 to present
- Deductible
- $2,437.82 of $3,500.0070%
- Out-of-pocket maximum
- $1,488.86 of $10,500.0014%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 9844256179
- Location
- Phoenix, AZ · TIN 77-3257014
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $261.00 | $161.82 | — | — | Review |
| Totals | $261.00 | $161.82 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-719489
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029742 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-01: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-000212, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (6920830281). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Primary Care Associates2026-05-01 12:42
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-05-20 03:20
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-20 08:24
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-000212, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018177 | 2026-07-15 | Mesa Behavioral Health | $191.00 | Approved |
| CLM-2026-000212 | 2026-05-01 | Canyon Primary Care Associates | $261.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.