CLM-2026-001595
Riverside Medical Group, Family Medicine. Service 2026-04-11 at office (POS 11). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Emily Ward
- Member ID
- UHC-88538-10
- Date of birth
- 1981-03-05
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-426072
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-3806
- Coverage period
- 2024-11-01 to present
- Deductible
- $609.26 of $1,000.0061%
- Out-of-pocket maximum
- $299.19 of $2,000.0015%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5595198842
- Network
- In network
- Rendering NPI
- 6811883605
- Location
- Atlanta, GA · TIN 63-8906521
- 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 | 90471 | Immunization administration | — | 1 | 1 | $40.00 | $24.80 | $24.80 | $0.00 | Paid |
| Totals | $40.00 | $24.80 | $24.80 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-897828
- 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-009039 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-11: N/A (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 3 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 Medical Group (5595198842). | |
| 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 Medical Group2026-04-11 13:27
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-2026-015654 | 2026-08-24 | Harbor Cardiovascular Associates | $1,681.00 | Approved |
| CLM-2026-023342 | 2025-12-31 | Mesa Medical Group | $88.00 | Denied |
| CLM-2026-023341 | 2025-12-31 | Mesa Medical Group | $88.00 | 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.