CLM-2026-000537
Unity Primary Care Associates, Family Medicine. Service 2026-03-24 at office (POS 11). Received 2026-04-07.
Member
Resolved through the identity graph
- Member
- Barbara Espinoza
- Member ID
- UHC-74131-02
- Date of birth
- 1953-03-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419033
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6708
- Coverage period
- 2025-12-01 to present
- Deductible
- $166.76 of $500.0033%
- Out-of-pocket maximum
- $393.01 of $1,000.0039%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8618575491
- Network
- In network
- Rendering NPI
- 2611847759
- Location
- San Diego, CA · TIN 48-6444371
- 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 | 36415 | Venipuncture | — | 1 | 1 | $14.00 | $8.68 | $8.68 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $302.00 | $187.24 | $0.00 | $187.24 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $328.00 | $203.36 | $0.00 | $203.36 | Paid |
| Totals | $644.00 | $399.28 | $8.68 | $390.60 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-637503
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024565 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-24: SELECT-EPO (EPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 14 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 Unity Primary Care Associates (8618575491). | |
| 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: Unity Primary Care Associates2026-03-24 17:38
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001805 | 2026-09-07 | Canyon Primary Care Associates | $176.00 | Approved |
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.