CLM-2026-007632
Riverside Medical Group, Family Medicine. Service 2025-10-28 at office (POS 11). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Billy Valdez
- Member ID
- UHC-52318-42
- Date of birth
- 1968-12-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420268
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9871
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,639.39 of $3,500.0047%
- Out-of-pocket maximum
- $3,234.14 of $7,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8250558730
- Network
- In network
- Rendering NPI
- 3570987560
- Location
- Nashville, TN · TIN 54-5227365
- 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 | $231.00 | $143.22 | — | — | DeniedCO29 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $251.00 | $155.62 | — | — | DeniedCO29 |
| Totals | $482.00 | $298.84 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-763218
- 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-004510 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-28: NULL (PPO), effective 2021-02-01. | |
| Timely filing | Fail | CO29 | Received 150 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 Riverside Medical Group (8250558730). | |
| 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 Medical Group2025-10-28 11:49
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-27 02:36
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)2026-03-27 17:28
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 150 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011601 | 2026-04-08 | Valley Community Hospital | $169.00 | Approved |
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.