CLM-2026-015953
Riverside Family Practice, Family Medicine. Service 2026-05-19 at office (POS 11). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Kimberly Delgado
- Member ID
- UHC-27985-96
- Date of birth
- 1961-12-14
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-431361
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5722
- Coverage period
- 2023-06-01 to present
- Deductible
- $546.57 of $1,500.0036%
- Out-of-pocket maximum
- $1,760.70 of $6,000.0029%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1193895335
- Network
- In network
- Rendering NPI
- 3878806371
- Location
- Los Angeles, CA · TIN 66-7778652
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $210.00 | $130.20 | $30.00 | $100.20 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $186.00 | $115.32 | $0.00 | $115.32 | Paid |
| Totals | $396.00 | $245.52 | $30.00 | $215.52 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-777247
- 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-031787 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-19: NULL (PPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 3 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 Family Practice (1193895335). | |
| 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 Family Practice2026-05-19 13:43
Patient seen for type 2 diabetes mellitus without complications.
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-2026-003712 | 2026-09-21 | Sunrise GI Associates | $4,787.00 | 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.