CLM-2026-013648
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-01-11 to 2026-01-12 at inpatient hospital (POS 21). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Katherine Carpenter
- Member ID
- UHC-20620-59
- Date of birth
- 1949-04-23
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-401204
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3317
- Coverage period
- 2021-09-01 to present
- Deductible
- $956.57 of $3,500.0027%
- Out-of-pocket maximum
- $462.96 of $10,500.004%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 3438227316
- Location
- Miami, FL · TIN 62-7720434
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $256.00 | $140.80 | — | — | DeniedCO18 |
| Totals | $256.00 | $140.80 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-720791
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-11 to 2026-01-15
- 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-006438 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-11: SELECT-EPO (EPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-013647: 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 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 Associates2026-01-12 09:58
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-02-11 00:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-720791.pdf7 pages
Itemised statement totalling $256.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-013647: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016848 | 2026-07-31 | Mesa Clinical Laboratories | $81.00 | Approved |
| CLM-2026-011985 | 2026-03-26 | Canyon Medical Group | $356.00 | Needs review |
| CLM-2026-013647 | 2026-01-11 | Riverside Internal Medicine Associates | $256.00 | 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
Exact duplicate of an earlier submission.