CLM-2026-000368
Riverside Family Practice, Family Medicine. Service 2026-05-14 at office (POS 11). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Nichoals Jackson
- Member ID
- UHC-76666-47
- Date of birth
- 1974-02-26
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416796
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5001
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,520.59 of $2,500.0061%
- Out-of-pocket maximum
- $74.09 of $10,000.001%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1193895335
- Network
- In network
- Rendering NPI
- 1133487284
- Location
- Los Angeles, CA · TIN 66-7778652
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $178.00 | $110.36 | $25.00 | $85.36 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $12.00 | $7.44 | $0.00 | $7.44 | Paid |
| Totals | $190.00 | $117.80 | $25.00 | $92.80 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-393075
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033863 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-14: NAVIGATE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Family Practice (1193895335). | |
| 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 Family Practice2026-05-14 16:06
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.