CLM-2026-015385
Desert Primary Care Associates, Family Medicine. Service 2026-05-13 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Nicole Hamilton
- Member ID
- UHC-21000-52
- Date of birth
- 1968-10-20
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-400663
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2499
- Coverage period
- 2024-07-01 to 2026-01-14
- Deductible
- $2,322.61 of $3,500.0066%
- Out-of-pocket maximum
- $4,376.76 of $14,000.0031%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6762345471
- Network
- In network
- Rendering NPI
- 1676402989
- Location
- Dallas, TX · TIN 75-4232082
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $291.00 | $180.42 | — | — | DeniedCO27 |
| Totals | $291.00 | $180.42 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-406792
- 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-006469 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-13 is after coverage terminated on 2026-01-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 Desert Primary Care Associates (6762345471). | |
| 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 Primary Care Associates2026-05-13 13:28
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-04 03:46
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-04 08:12
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-13 is after coverage terminated on 2026-01-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022522 | 2026-07-26 | Riverside Medical Group | $273.00 | Denied |
| CLM-2026-014447 | 2025-12-10 | Unity Family Practice | $25.00 | 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
Service after coverage termination.