CLM-2026-001501
Unity Primary Care Associates, Family Medicine. Service 2025-11-26 at office (POS 11). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Martha Lewis
- Member ID
- UHC-83453-88
- Date of birth
- 2005-07-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423630
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6169
- Coverage period
- 2021-12-01 to present
- Deductible
- $296.97 of $2,500.0012%
- Out-of-pocket maximum
- $3,123.79 of $7,500.0042%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8247321622
- Network
- Out of network
- Rendering NPI
- 8275148764
- Location
- Tempe, AZ · TIN 17-5198361
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $313.00 | $140.85 | — | — | PendedCO16 |
| Totals | $313.00 | $140.85 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-170903
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000114 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-26: N/A (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 36 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Primary Care Associates2025-11-26 10:09
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-01 05:34
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
- AI recommendationPended2026-10-21 14:05The claim is for a preventive visit for essential hypertension, which is a covered service. However, the clinical note is incomplete as it is pending a signature, and a development letter has been sent to the provider. The claim is pended for the provider to submit the complete documentation.
- Examiner decisionPended2026-10-21 14:06Agree with the AI review: the clinical note is unsigned and a development letter is outstanding. Hold until the provider returns the signed note.
- AI recommendation recordedAI adjudicator (Claude on Bedrock)2026-10-21 14:05 · 82a350d7
- Claim decision recordedR. Patel (Claims Examiner II)2026-10-21 14:06 · 26cd3ce8
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is for a preventive visit for essential hypertension, which is a covered service. However, the clinical note is incomplete as it is pending a signature, and a development letter has been sent to the provider. The claim is pended for the provider to submit the complete documentation.
Examiner decision
Recorded by R. Patel (Claims Examiner II) at 2026-10-21 14:06
Agree with the AI review: the clinical note is unsigned and a development letter is outstanding. Hold until the provider returns the signed note.
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.