Professional claim · CMS-1500 · EDI 837P
CLM-2026-011264
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-03-21 at office (POS 11). Received 2026-04-23.
DeniedOut of network
Billed
$318.00
2 lines
Allowed
$143.10
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Melissa Dean
- Member ID
- UHC-69799-61
- Date of birth
- 1947-06-22
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-422658
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5475
- Coverage period
- 2022-06-01 to 2026-02-19
- Deductible
- $414.69 of $500.0083%
- Out-of-pocket maximum
- $519.33 of $1,500.0035%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 1273338578
- 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 | 59 | 1 | 1 | $43.00 | $19.35 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 2 | $275.00 | $123.75 | — | — | DeniedCO27 |
| Totals | $318.00 | $143.10 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-411835
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009071 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-21 is after coverage terminated on 2026-02-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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) | 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Internal Medicine Associates2026-03-21 13:44
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-23 03:22
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-21 is after coverage terminated on 2026-02-19. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028473 | 2026-01-21 | Canyon Reference Lab | $52.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.