CLM-2026-009052
Riverside Primary Care Associates, Family Medicine. Service 2026-08-18 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Dylan Reid
- Member ID
- UHC-31001-11
- Date of birth
- 2002-07-28
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-406263
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0478
- Coverage period
- 2025-09-01 to present
- Deductible
- $97.38 of $2,500.004%
- Out-of-pocket maximum
- $588.08 of $5,000.0012%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 4629857564
- Location
- Phoenix, AZ · TIN 77-3257014
- 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 | $147.00 | $91.14 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $316.00 | $195.92 | — | — | Review |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $309.00 | $191.58 | — | — | Review |
| Totals | $772.00 | $478.64 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-228210
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038134 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-18: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 30 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-2026-009051; 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 Primary Care Associates (6920830281). | |
| 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 Associates2026-08-18 12:56
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-09-17 00:39
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-17 13:49
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-009051.pdf1 page
Provider cover letter requesting replacement of CLM-2026-009051.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-009051; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009051 | 2026-08-18 | Riverside Primary Care Associates | $772.00 | 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.