CLM-2026-003886
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-09-06 at office (POS 11). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Harold Patterson
- Member ID
- UHC-04603-36
- Date of birth
- 1940-03-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-412738
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8993
- Coverage period
- 2025-02-01 to present
- Deductible
- $121.64 of $2,500.005%
- Out-of-pocket maximum
- $1,738.75 of $5,000.0035%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 7085028620
- Location
- Denver, CO · TIN 43-9760539
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $74.00 | $33.30 | — | — | DeniedCO204 |
| Totals | $74.00 | $33.30 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-299888
- 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-009556 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-06: SELECT-EPO (EPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 19 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 9956855107 is out of network and the EPO 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: Riverside Internal Medicine Associates2026-09-06 10:25
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-09-25 06:48
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 9956855107 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001025 | 2026-09-17 | Sunrise Cardiovascular Associates | $337.00 | Denied |
| CLM-2026-015000 | 2026-03-12 | Evergreen Digestive Health Center | $4,562.00 | Approved |
| CLM-2026-025773 | 2025-12-28 | Mesa Internal Medicine Associates | $90.00 | 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.