CLM-2026-005610
Desert Family Practice, Family Medicine. Service 2026-07-24 at office (POS 11). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Elijah Gilbert
- Member ID
- UHC-00785-53
- Date of birth
- 1998-08-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-427950
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4048
- Coverage period
- 2021-09-01 to 2026-04-27
- Deductible
- $1,905.39 of $2,500.0076%
- Out-of-pocket maximum
- $1,274.75 of $7,500.0017%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8144042321
- Network
- In network
- Rendering NPI
- 5618629203
- Location
- Miami, FL · TIN 86-4678898
- 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 | 90471 | Immunization administration | — | 1 | 1 | $36.00 | $22.32 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $24.00 | $14.88 | — | — | DeniedCO27 |
| Totals | $60.00 | $37.20 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-210906
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039217 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-24 is after coverage terminated on 2026-04-27. 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 | Pass | In-network provider Desert Family Practice (8144042321). | |
| 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: Desert Family Practice2026-07-24 09:59
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-07-31 06:21
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-31 17:51
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-24 is after coverage terminated on 2026-04-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002843 | 2026-06-13 | Pinecrest Heart Institute | $593.00 | Denied |
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.