CLM-2026-001787
Riverside Medical Group, Family Medicine. Service 2026-04-11 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Alice Hayes
- Member ID
- none on golden record
- Date of birth
- 2000-06-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407884
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-8233
- Coverage period
- 2025-06-01 to present
- Deductible
- $323.29 of $1,000.0032%
- Out-of-pocket maximum
- $1,315.85 of $3,000.0044%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8250558730
- Network
- In network
- Rendering NPI
- 5419106161
- Location
- Nashville, TN · TIN 54-5227365
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $175.00 | $108.50 | — | — | PendedIDQ |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $12.00 | $7.44 | — | — | PendedIDQ |
| Totals | $187.00 | $115.94 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-286120
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002781; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-11: OPTIONS-PPO (PPO), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 5 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 (8250558730). | |
| 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 09:13
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002781; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-11: OPTIONS-PPO (PPO), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.