CLM-2026-012607
Valley Family Practice, Family Medicine. Service 2026-06-10 at office (POS 11). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Scott Ortega
- Member ID
- UHC-63453-39
- Date of birth
- 1964-08-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400159
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group UNKNOWN
- Coverage period
- 2024-09-01 to 2026-05-17
- Deductible
- $893.06 of $2,500.0036%
- Out-of-pocket maximum
- $2,432.93 of $7,500.0032%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 1714828724
- Location
- Houston, TX · TIN 34-3279519
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $313.00 | $194.06 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | 25 | 1 | 1 | $17.00 | $10.54 | — | — | DeniedCO27 |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $26.66 | — | — | DeniedCO27 |
| Totals | $373.00 | $231.26 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-747884
- 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-023322 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-10 is after coverage terminated on 2026-05-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 Valley Family Practice (3411841638). | |
| 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: Valley Family Practice2026-06-10 09:20
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-04 06:48
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-04 11:02
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 12:44Eligibility: Date of service 2026-06-10 is after coverage terminated on 2026-05-17.
Other claims for this member
Same resolved identity
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
Service after coverage termination.