CLM-2026-013559
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-01-29 at office (POS 11). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Austin Clark
- Member ID
- UHC-09557-64
- Date of birth
- 2007-06-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419190
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0879
- Coverage period
- 2023-06-01 to present
- Deductible
- $306.88 of $500.0061%
- Out-of-pocket maximum
- $48.90 of $2,000.002%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 4421420611
- Location
- Miami, FL · TIN 62-7720434
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $306.00 | $189.72 | $20.00 | $169.72 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $277.00 | $171.74 | $0.00 | $171.74 | Paid |
| Totals | $583.00 | $361.46 | $20.00 | $341.46 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-534103
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015000 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-29: SELECT-EPO (EPO), effective 2023-06-01. | |
| 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 Riverside Internal Medicine Associates (5379926517). | |
| 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: Riverside Internal Medicine Associates2026-01-29 17:16
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021312 | 2026-02-23 | Harbor Regional Medical Center | $140.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.