CLM-2026-009390
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-01-06 at office (POS 11). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Donna Owens
- Member ID
- UHC-44246-61
- Date of birth
- 1956-08-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423671
- Relationship
- Child, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-5183
- Coverage period
- 2022-02-01 to present
- Deductible
- $320.78 of $500.0064%
- Out-of-pocket maximum
- $278.96 of $1,000.0028%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 3723348124
- Location
- Denver, CO · TIN 43-9760539
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $73.00 | $32.85 | — | — | PendedIDQ |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $225.00 | $101.25 | — | — | PendedIDQ |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $79.00 | $35.55 | — | — | PendedIDQ |
| Totals | $377.00 | $169.65 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-916385
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002098; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-01-06: - (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 22 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Internal Medicine Associates2026-01-06 18:00
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002098; payment withheld until the identity is confirmed. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.