Claims workbench/CLM-2026-013044

Professional claim · CMS-1500 · EDI 837P

CLM-2026-013044

Riverside Primary Care Associates, Family Medicine. Service 2026-02-01 at office (POS 11). Received 2026-08-09.

Denied

Billed

$188.00

1 line

Allowed

$116.56

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Ethan Estrada
Member ID: UHC-68529-89
Date of birth: 1966-04-28
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-402518
Relationship: Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-1849
Coverage period: 2024-03-01 to present
Deductible: $1,293.60 of $1,500.0086%
Out-of-pocket maximum: $23.51 of $3,000.001%
Copays: office $20.00, specialist $50.00, emergency $250.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 6920830281
Network: In network
Rendering NPI: 8461512922
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	$188.00	$116.56	—	—	DeniedCO29
Totals						$188.00	$116.56	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. M54.50 Low back pain, unspecified
3. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-178527
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-007062 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-02-01: N/A (PPO), effective 2024-03-01.
Timely filing	Fail	CO29	Received 189 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Primary Care Associates2026-02-01 13:38
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-08-09 03:44
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-09 17:18
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 189 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-021248	2026-08-12	Mesa Bone and Joint Center	$2,972.00	Needs review
CLM-2026-033557	2026-01-11	Cornerstone Reference Lab	$51.00	Approved
CLM-2026-010384	2026-01-04	Cornerstone Bone and Joint Center	$229.00	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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity