CLM-2026-007967
Riverside Primary Care Associates, Family Medicine. Service 2025-11-12 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Andrea Howell
- Member ID
- UHC-41300-78
- Date of birth
- 1951-10-20
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424440
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2625
- Coverage period
- 2021-06-01 to present
- Deductible
- $148.47 of $2,500.006%
- Out-of-pocket maximum
- $2,384.25 of $7,500.0032%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8662496362
- Network
- In network
- Rendering NPI
- 6450621381
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $251.00 | $155.62 | — | — | DeniedCO29 |
| Totals | $251.00 | $155.62 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-136027
- 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-014886 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-12: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Fail | CO29 | Received 204 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 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 Associates2025-11-12 16:43
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-06-04 01:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
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 204 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000307 | 2026-05-26 | Lakeside Medical Group | $454.00 | Approved |
| CLM-2026-033686 | 2026-03-11 | Sunrise Counseling Center | $2,675.00 | Needs review |
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.