CLM-2026-004731
Unity Primary Care Associates, Family Medicine. Service 2025-11-30 at office (POS 11). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Vincent Diaz
- Member ID
- UHC-09083-91
- Date of birth
- 1958-10-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421312
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9671
- Coverage period
- 2025-05-01 to present
- Deductible
- $237.82 of $1,500.0016%
- Out-of-pocket maximum
- $366.67 of $3,000.0012%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 2766831707
- Location
- Charlotte, NC · TIN 92-2641302
- 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 | 36415 | Venipuncture | — | 1 | 1 | $25.00 | $11.25 | — | — | DeniedCO29 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $322.00 | $144.90 | — | — | DeniedCO29 |
| Totals | $347.00 | $156.15 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-173167
- 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-006524 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-30: CHOICE-PLUS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Fail | CO29 | Received 127 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Primary Care Associates2025-11-30 15:04
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-04-06 03:02
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 127 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033858 | 2026-07-04 | Lakeside Bone and Joint Center | $45,619.00 | Needs review |
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.