CLM-2026-005564
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-07-22 at office (POS 11). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Julia Ryan
- Member ID
- UHC-35022-68
- Date of birth
- 1955-06-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424296
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2477
- Coverage period
- 2023-05-01 to 2026-03-06
- Deductible
- $174.20 of $500.0035%
- Out-of-pocket maximum
- $204.63 of $1,000.0020%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 6021495562
- Location
- Miami, FL · TIN 62-7720434
- Authorisation / referral
- none / REF134541
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 | $76.00 | $47.12 | — | — | DeniedCO27 |
| Totals | $76.00 | $47.12 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-395819
- 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-039052 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-03-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 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 | Pass | In-network provider Riverside Internal Medicine Associates (5379926517). | |
| 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 Associates2026-07-22 10:28
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-27 01:49
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-27 08:45
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-03-06.
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
Service after coverage termination.