CLM-2026-001766
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-03-22 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Philip Tucker
- Member ID
- UHC-10045-77
- Date of birth
- 1951-04-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421949
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0141
- Coverage period
- 2022-04-01 to present
- Deductible
- $526.50 of $1,000.0053%
- Out-of-pocket maximum
- $689.16 of $3,000.0023%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 3105708283
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $311.00 | $192.82 | — | — | DeniedCO29 |
| Totals | $311.00 | $192.82 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-296110
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034220 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-22: MEDICARE-ADV-B (MA), effective 2022-04-01. | |
| Timely filing | Fail | CO29 | Received 108 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Associates2026-03-22 14:49
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-08 02:56
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 108 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019276 | 2026-04-25 | Meadow Dermatology Clinic | $451.00 | Approved |
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
Received after the timely-filing limit.