CLM-2026-013216
Unity Primary Care Associates, Family Medicine. Service 2026-02-11 at office (POS 11). Received 2026-02-27.
Member
Resolved through the identity graph
- Member
- Frank Diaz
- Member ID
- UHC-16569-25
- Date of birth
- 1999-04-24
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-408519
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6604
- Coverage period
- 2023-08-01 to 2026-05-16
- Deductible
- $860.26 of $1,000.0086%
- Out-of-pocket maximum
- $38.03 of $3,000.001%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 2192557207
- Location
- Charlotte, NC · TIN 92-2641302
- 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 | $9.00 | — | — | DeniedCO204 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $197.00 | $88.65 | — | — | DeniedCO204 |
| Totals | $217.00 | $97.65 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-153466
- 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-016190 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-11: SELECT-EPO (EPO), effective 2023-08-01, terms 2026-05-16. | |
| Timely filing | Pass | Received 16 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 | Fail | CO204 | Billing provider 3636526220 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Unity Primary Care Associates2026-02-11 16:05
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-02-27 03:10
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-27 09:28
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 12:44Provider network: Billing provider 3636526220 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005824 | 2026-05-07 | Sunrise Counseling Center | $193.00 | Approved |
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
No out-of-network benefit on this plan.