CLM-2026-012113
Riverside Primary Care Associates, Family Medicine. Service 2025-09-03 at office (POS 11). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Helen Williams
- Member ID
- UHC-69324-22
- Date of birth
- 1978-04-25
- Identity
- Verified5 records, confidence 0.98
- Claim record
- CLMCLM-422519
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2021-06-01 to present
- Deductible
- $1,494.48 of $2,500.0060%
- Out-of-pocket maximum
- $1,525.27 of $5,000.0031%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 7261381298
- Location
- Phoenix, AZ · TIN 77-3257014
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $190.00 | $117.80 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $318.00 | $197.16 | — | — | DeniedCO29 |
| Totals | $508.00 | $314.96 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-536240
- 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-006695 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-09-03: NULL (PPO), effective 2021-06-01. | |
| Timely filing | Fail | CO29 | Received 141 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (6920830281). | |
| 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 Primary Care Associates2025-09-03 10:11
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-01-22 02:32
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 141 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009050 | 2026-01-14 | Mesa Medical Group | $222.00 | Needs review |
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
Received after the timely-filing limit.