CLM-2026-008357
Riverside Medical Group, Family Medicine. Service 2026-06-21 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Hnnah Nelson
- Member ID
- UHC-90359-46
- Date of birth
- 1986-09-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425578
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0650
- Coverage period
- 2025-12-01 to present
- Deductible
- $172.02 of $1,000.0017%
- Out-of-pocket maximum
- $304.16 of $3,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5595198842
- Network
- In network
- Rendering NPI
- 5478255719
- Location
- Atlanta, GA · TIN 63-8906521
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $332.00 | $205.84 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $261.00 | $161.82 | — | — | Review |
| Totals | $593.00 | $367.66 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-345102
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036433 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-21: MEDICARE-ADV-B (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-008356; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Medical Group (5595198842). | |
| 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 Group2026-06-21 15:56
Patient seen for low back pain, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-07-07 01:11
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-008356.pdf1 page
Provider cover letter requesting replacement of CLM-2026-008356.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-008356; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008356 | 2026-06-21 | Riverside Medical Group | $593.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.