CLM-2026-003624
Riverside Medical Group, Family Medicine. Service 2026-06-08 at office (POS 11). Received 2026-06-16.
Member
Resolved through the identity graph
- Member
- Margaret Stevens
- Member ID
- UHC-74068-29
- Date of birth
- 1981-12-12
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-423765
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group UNKNOWN
- Coverage period
- 2021-04-01 to present
- Deductible
- $273.07 of $1,500.0018%
- Out-of-pocket maximum
- $2,227.21 of $6,000.0037%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- 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
- 2907913232
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $220.00 | $136.40 | $20.00 | $116.40 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $185.00 | $114.70 | $0.00 | $114.70 | Paid |
| Totals | $405.00 | $251.10 | $20.00 | $231.10 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-416165
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011123 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-08: CORE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 8 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 Group2026-06-08 10:04
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022164 | 2025-12-25 | Valley Regional Medical Center | $4,482.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.