CLM-2026-004739
Valley Medical Group, Family Medicine. Service 2025-10-15 at office (POS 11). Received 2026-02-28.
Member
Resolved through the identity graph
- Member
- Kevin Knight
- Member ID
- UHC-45883-68
- Date of birth
- 1953-01-22
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-425989
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4943
- Coverage period
- 2025-09-01 to present
- Deductible
- $357.47 of $1,000.0036%
- Out-of-pocket maximum
- $152.15 of $2,000.008%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5938488512
- Network
- In network
- Rendering NPI
- 6836143365
- Location
- Tempe, AZ · TIN 76-2268417
- 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 | $215.00 | $133.30 | — | — | DeniedCO29 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $208.00 | $128.96 | — | — | DeniedCO29 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $220.00 | $136.40 | — | — | DeniedCO29 |
| Totals | $643.00 | $398.66 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-431404
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016463 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2025-10-15: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Fail | CO29 | Received 136 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 | Pass | In-network provider Valley Medical Group (5938488512). | |
| 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: Valley Medical Group2025-10-15 12:32
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-28 06:16
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-28 10:11
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 136 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.