CLM-2026-003455
Unity Family Practice, Family Medicine. Service 2026-08-22 at office (POS 11). Received 2026-09-18.
Member
Resolved through the identity graph
- Member
- Anna Dunn
- Member ID
- UHC-36655-13
- Date of birth
- 1979-05-15
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-410429
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2304
- Coverage period
- 2023-07-01 to 2026-07-27
- Deductible
- $711.36 of $1,000.0071%
- Out-of-pocket maximum
- $359.93 of $3,000.0012%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1322196548
- Network
- In network
- Rendering NPI
- 4313210591
- Location
- Atlanta, GA · TIN 29-1244734
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $204.00 | $126.48 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $19.00 | $11.78 | — | — | DeniedCO27 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $334.00 | $207.08 | — | — | DeniedCO27 |
| Totals | $557.00 | $345.34 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-495766
- 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-015284 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-22 is after coverage terminated on 2026-07-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 Unity Family Practice (1322196548). | |
| 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 Family Practice2026-08-22 15:14
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-18 05:21
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-18 13:19
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-22 is after coverage terminated on 2026-07-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016867 | 2026-08-17 | Canyon Medical Group | $161.00 | Denied |
| CLM-2026-011328 | 2026-02-10 | Evergreen Clinical Laboratories | $43.00 | 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
Service after coverage termination.