CLM-2026-009307
Riverside Medical Group, Family Medicine. Service 2026-08-23 at office (POS 11). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Philip Harris
- Member ID
- UHC-05604-54
- Date of birth
- 1963-02-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427128
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group -
- Coverage period
- 2023-07-01 to 2026-08-23
- Deductible
- $2,165.75 of $2,500.0087%
- Out-of-pocket maximum
- $3,343.81 of $10,000.0033%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5595198842
- Network
- In network
- Rendering NPI
- 4512058494
- 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 | $222.00 | $137.64 | $25.00 | $112.64 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $24.00 | $14.88 | $0.00 | $14.88 | Paid |
| Totals | $246.00 | $152.52 | $25.00 | $127.52 | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-361253
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-043317 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-23: MEDICARE-ADV-A (MA), effective 2023-07-01, terms 2026-08-23. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| 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 (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 Group2026-08-23 17:09
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-04 04:10
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-04 08:57
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.