CLM-2026-009700
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-06-16 at office (POS 11). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Anthony Elliott
- Member ID
- UHC-53370-86
- Date of birth
- 1957-04-07
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-417637
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3506
- Coverage period
- 2025-08-01 to present
- Deductible
- $306.39 of $1,000.0031%
- Out-of-pocket maximum
- $1,198.58 of $4,000.0030%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 5289885969
- Location
- Denver, CO · TIN 43-9760539
- Authorisation / referral
- none / REF473687
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $81.00 | $36.45 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $389.00 | $175.05 | — | — | DeniedCO204 |
| Totals | $470.00 | $211.50 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-975811
- 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-020909 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-16: CORE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 15 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 | Fail | CO204 | Billing provider 9956855107 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-06-16 17:27
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-01 03:36
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 9956855107 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030494 | 2026-08-18 | Sunrise Bone and Joint Center | $437.00 | Approved |
| CLM-2026-030808 | 2026-06-12 | Heritage Behavioral Health | $349.00 | Approved |
| CLM-2026-025886 | 2026-03-15 | Canyon Counseling Center | $245.00 | Denied |
| CLM-2026-019138 | 2026-02-11 | Heritage Family Practice | $41.00 | Approved |
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
No out-of-network benefit on this plan.