CLM-2026-002258
Desert Primary Care Associates, Family Medicine. Service 2025-11-27 at office (POS 11). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Julia Bailey
- Member ID
- UHC-66212-73
- Date of birth
- 1954-05-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402379
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7040
- Coverage period
- 2024-11-01 to present
- Deductible
- $104.47 of $500.0021%
- Out-of-pocket maximum
- $138.74 of $1,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6762345471
- Network
- In network
- Rendering NPI
- 1290686892
- Location
- Dallas, TX · TIN 75-4232082
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $232.00 | $143.84 | — | — | DeniedCO18 |
| Totals | $232.00 | $143.84 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-740344
- 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-002512 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-27: NAVIGATE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 59 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002257: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Primary Care Associates (6762345471). | |
| 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: Desert Primary Care Associates2025-11-27 17:13
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-25 02:54
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-002257: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006367 | 2026-09-23 | Harbor Rehabilitation Center | $460.00 | Approved |
| CLM-2026-002257 | 2025-11-27 | Desert Primary Care Associates | $232.00 | 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
Exact duplicate of an earlier submission.