CLM-2026-001715
Valley Internal Medicine Associates, Internal Medicine. Service 2026-05-06 at office (POS 11). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Mark Contreras
- Member ID
- UHC-18319-57
- Date of birth
- 1994-06-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416977
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4070
- Coverage period
- 2022-07-01 to 2026-02-26
- Deductible
- $692.86 of $2,500.0028%
- Out-of-pocket maximum
- $3,080.61 of $10,000.0031%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5095030487
- Network
- In network
- Rendering NPI
- 4280163310
- Location
- Charlotte, NC · TIN 47-3292895
- Authorisation / referral
- none / REF881803
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $353.00 | $218.86 | — | — | DeniedCO27 |
| Totals | $353.00 | $218.86 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-928800
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025523 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-06 is after coverage terminated on 2026-02-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 Valley Internal Medicine Associates (5095030487). | |
| 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: Valley Internal Medicine Associates2026-05-06 12:48
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-05-13 02:26
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-13 08:18
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-06 is after coverage terminated on 2026-02-26.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.