Professional claim · CMS-1500 · EDI 837P
CLM-2026-012960
Valley Medical Group, Internal Medicine. Service 2026-05-30 at office (POS 11). Received 2026-07-01.
Denied
Billed
$402.00
3 lines
Allowed
$249.24
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Fatima Jacobs
- Member ID
- UHC-41356-33
- Date of birth
- 1974-02-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-432224
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2189
- Coverage period
- 2022-08-01 to 2026-01-23
- Deductible
- $253.09 of $2,500.0010%
- Out-of-pocket maximum
- $161.44 of $10,000.002%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 2599807650
- Location
- Nashville, TN · TIN 16-4753822
- Authorisation / referral
- none / REF537854
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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $243.00 | $150.66 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1,2 | $50.00 | $31.00 | — | — | DeniedCO27 |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $109.00 | $67.58 | — | — | DeniedCO27 |
| Totals | $402.00 | $249.24 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-979737
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006607 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-30 is after coverage terminated on 2026-01-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 Medical Group (1946396904). | |
| 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: Valley Medical Group2026-05-30 10:19
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-01 05:58
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 2026-05-30 is after coverage terminated on 2026-01-23. 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-2026-027676 | 2026-07-27 | Summit Clinical Laboratories | $64.00 | Denied |
| CLM-2026-033286 | 2026-05-21 | Pinecrest Medical Group | $303.00 | Denied |
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.