CLM-2026-013105
Desert Family Practice, Family Medicine. Service 2026-05-14 at office (POS 11). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Rachel Espinoza
- Member ID
- UHC-88110-90
- Date of birth
- 1979-08-22
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-432676
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5624
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,461.39 of $2,500.0058%
- Out-of-pocket maximum
- $2,061.98 of $5,000.0041%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8144042321
- Network
- In network
- Rendering NPI
- 6851972698
- Location
- Miami, FL · TIN 86-4678898
- 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 | 36415 | Venipuncture | — | 1 | 1 | $20.00 | $12.40 | — | — | DeniedCO18 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $278.00 | $172.36 | — | — | DeniedCO18 |
| Totals | $298.00 | $184.76 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-983334
- 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-006196 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-14: OPTIONS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-013104: 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 Desert Family Practice (8144042321). | |
| 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: Desert Family Practice2026-05-14 14:35
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-04 05:09
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-04 15:42
Called the provider office; awaiting documentation.
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-2026-013104: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013104 | 2026-05-14 | Desert Family Practice | $298.00 | Approved |
| CLM-2026-029126 | 2025-12-14 | Canyon Diagnostic Imaging | $1,440.00 | 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
Exact duplicate of an earlier submission.