CLM-2026-011541
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-01-17 at office (POS 11). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Jacob Rose
- Member ID
- UHC-83239-78
- Date of birth
- 1989-01-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-430796
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-7561
- Coverage period
- 2024-10-01 to present
- Deductible
- $357.23 of $500.0071%
- Out-of-pocket maximum
- $166.76 of $1,000.0017%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 1627051331
- Location
- Miami, FL · TIN 62-7720434
- 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 | $83.00 | $51.46 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $260.00 | $161.20 | — | — | DeniedCO18 |
| Totals | $343.00 | $212.66 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-262980
- 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-008243 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-17: N/A (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-011540: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Internal Medicine Associates (5379926517). | |
| 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 Associates2026-01-17 09:11
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-02-13 04:34
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-13 14:52
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-011540: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011540 | 2026-01-17 | Riverside Internal Medicine Associates | $343.00 | 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
Exact duplicate of an earlier submission.