CLM-2026-005273
Riverside Primary Care Associates, Family Medicine. Service 2026-05-07 at office (POS 11). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Kyle Ward
- Member ID
- UHC-48973-10
- Date of birth
- 1996-05-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406131
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8480
- Coverage period
- 2022-03-01 to present
- Deductible
- $565.42 of $2,500.0023%
- Out-of-pocket maximum
- $452.72 of $5,000.009%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8662496362
- Network
- In network
- Rendering NPI
- 1077096158
- Location
- Austin, TX · TIN 71-8699033
- 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 | $12.00 | $7.44 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $230.00 | $142.60 | — | — | Review |
| 3 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1 | $167.00 | $103.54 | — | — | Review |
| Totals | $409.00 | $253.58 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-478631
- 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-014934 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-07: CORE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-005272, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (8662496362). | |
| 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 Primary Care Associates2026-05-07 14:18
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-01 03:58
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-01 13:01
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-005272, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005272 | 2026-05-07 | Heritage Primary Care Associates | $409.00 | Approved |
| CLM-2026-019054 | 2026-04-05 | Meadow Physical Therapy | $371.00 | Denied |
| CLM-2026-029611 | 2026-02-05 | Northgate Orthopedic Specialists | $280.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.