Claims workbench/CLM-2026-006541

Professional claim · CMS-1500 · Provider portal

CLM-2026-006541

Unity Primary Care Associates, Family Medicine. Service 2026-02-19 at office (POS 11). Received 2026-08-06.

DeniedOut of network

Billed

$503.00

2 lines

Allowed

$226.35

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Andrea Carlson
Member ID: UHC-03381-49
Date of birth: 1970-07-16
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-424772
Relationship: Child, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-4232
Coverage period: 2021-02-01 to present
Deductible: $1,003.87 of $1,500.0067%
Out-of-pocket maximum: $902.29 of $3,000.0030%
Copays: office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Unity Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 3636526220
Network: Out of network
Rendering NPI: 7401789525
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	99213	Office visit, established patient, low complexity	—	1	1	$191.00	$85.95	—	—	DeniedCO29
2	99214	Office visit, established patient, moderate complexity	—	1	1,2	$312.00	$140.40	—	—	DeniedCO29
Totals						$503.00	$226.35	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-544976
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-035946 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-02-19: - (PPO), effective 2021-02-01.
Timely filing	Fail	CO29	Received 168 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Primary Care Associates2026-02-19 16:24
Patient seen for acute upper respiratory infection, unspecified.
SystemSystem: Claims system2026-08-06 05:18
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-06 10:08
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 168 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-2026-012159	2026-07-06	Mesa Bone and Joint Center	$194.00	Approved
CLM-2026-027034	2026-05-21	Meadow Diagnostic Imaging	$135.00	Needs review
CLM-2026-027033	2026-05-21	Lakeside Imaging Center	$135.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity