Professional claim · CMS-1500 · EDI 837P
CLM-2026-004676
Valley Primary Care Associates, Family Medicine. Service 2026-09-30 at office (POS 11). Received 2026-10-07.
DeniedOut of network
Billed
$441.00
2 lines
Allowed
$198.45
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Walter Hoffman
- Member ID
- UHC-83616-67
- Date of birth
- 1965-04-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418524
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7232
- Coverage period
- 2024-12-01 to 2026-01-03
- Deductible
- $1,517.79 of $2,500.0061%
- Out-of-pocket maximum
- $1,498.88 of $5,000.0030%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 8445641599
- Location
- Denver, CO · TIN 69-3521502
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $187.00 | $84.15 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $254.00 | $114.30 | — | — | DeniedCO27 |
| Totals | $441.00 | $198.45 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-959505
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033422 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-30 is after coverage terminated on 2026-01-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 6179468650 is out of network and the HMO 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Primary Care Associates2026-09-30 13:35
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-07 04:37
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-30 is after coverage terminated on 2026-01-03. Provider network: Billing provider 6179468650 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.