CLM-2026-001861
Unity Primary Care Associates, Family Medicine. Service 2026-05-10 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Doris Mendez
- Member ID
- UHC-89129-89
- Date of birth
- 1997-11-25
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-431043
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7243
- Coverage period
- 2022-11-01 to 2026-05-13
- Deductible
- $1,726.73 of $2,500.0069%
- Out-of-pocket maximum
- $1,989.35 of $7,500.0027%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- 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
- 9396184886
- 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 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $19.35 | — | — | DeniedCO204 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $21.00 | $9.45 | — | — | DeniedCO204 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $149.00 | $67.05 | — | — | DeniedCO204 |
| Totals | $213.00 | $95.85 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-519387
- 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-007330 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-05-10: NAVIGATE-HMO (HMO), effective 2022-11-01, terms 2026-05-13. | |
| Timely filing | Pass | Received 13 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 | Fail | CO204 | Billing provider 8247321622 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Unity Primary Care Associates2026-05-10 13:29
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-23 01:08
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8247321622 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021718 | 2026-06-09 | Evergreen Medical Group | $280.00 | Denied |
| CLM-2026-021806 | 2026-01-12 | Sunrise Diagnostic Imaging | $524.00 | 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
No out-of-network benefit on this plan.