CLM-2026-002663
Desert Primary Care Associates, Family Medicine. Service 2025-12-16 at office (POS 11). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Henry Little
- Member ID
- UHC-93359-73
- Date of birth
- 1944-12-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403748
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2610
- Coverage period
- 2023-02-01 to present
- Deductible
- $13.95 of $500.003%
- Out-of-pocket maximum
- $302.77 of $1,000.0030%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8080835506
- Network
- In network
- Rendering NPI
- 1767671757
- Location
- Denver, CO · TIN 39-5381376
- 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 | $244.00 | $151.28 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $13.00 | $8.06 | — | — | DeniedCO29 |
| Totals | $257.00 | $159.34 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-642315
- 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-001424 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-16: CHOICE-PLUS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Fail | CO29 | Received 140 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 Desert Primary Care Associates (8080835506). | |
| 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 Associates2025-12-16 10:47
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-05-05 00:08
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 engineDenied2026-10-21 13:43Timely filing: Received 140 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025871 | 2026-05-04 | Summit Digestive Health Center | $1,866.00 | Approved |
| CLM-2026-031331 | 2026-04-02 | Evergreen Counseling Center | $299.00 | Approved |
| CLM-2026-021131 | 2026-03-29 | Meadow Diagnostic Imaging | $4,017.00 | Approved |
| CLM-2026-006108 | 2026-02-13 | Northgate Orthopedic Specialists | $6,734.00 | 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.