CLM-2026-010442
Desert Primary Care Associates, Family Medicine. Service 2026-05-27 at office (POS 11). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Janet Reyes
- Member ID
- UHC-74672-84
- Date of birth
- 1951-06-01
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-418216
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7813
- Coverage period
- 2022-04-01 to present
- Deductible
- $167.47 of $500.0033%
- Out-of-pocket maximum
- $288.61 of $1,000.0029%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6762345471
- Network
- In network
- Rendering NPI
- 1279466977
- Location
- Dallas, TX · TIN 75-4232082
- 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 | 36415 | Venipuncture | 59 | 1 | 1 | $23.00 | $14.26 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 2 | $195.00 | $120.90 | — | — | Review |
| Totals | $218.00 | $135.16 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-180272
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034069 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-05-27: MEDICARE-ADV-A (MA), effective 2022-04-01. | |
| 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 Desert Primary Care Associates (6762345471). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Desert Primary Care Associates2026-05-27 18:23
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-06-08 02:55
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-08 13:58
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-180272.pdf17 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Bundled code pair; modifier 59 not supported by the operative note.