CLM-2026-000834
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-01-25 at office (POS 11). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Mei Carter
- Member ID
- UHC-88572-18
- Date of birth
- 1992-06-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-423611
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3826
- Coverage period
- 2022-09-01 to present
- Deductible
- $155.35 of $1,500.0010%
- Out-of-pocket maximum
- $899.82 of $3,000.0030%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 8963888267
- Location
- Miami, FL · TIN 62-7720434
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $74.00 | $45.88 | $25.00 | $20.88 | Paid |
| Totals | $74.00 | $45.88 | $25.00 | $20.88 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-255354
- 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-008040 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-25: MEDICARE-ADV-B (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 2 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 Internal Medicine Associates (5379926517). | |
| 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 Internal Medicine Associates2026-01-25 15:30
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024577 | 2026-09-10 | Meadow Heart Institute | $1,449.00 | Needs review |
| CLM-2026-024576 | 2026-09-10 | Meadow Heart Institute | $1,449.00 | 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.