Professional claim · CMS-1500 · EDI 837P
CLM-2026-016145
Unity Primary Care Associates, Family Medicine. Service 2026-08-31 at office (POS 11). Received 2026-09-12.
Denied
Billed
$500.00
2 lines
Allowed
$310.00
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Larry Jones
- Member ID
- UHC-94064-39
- Date of birth
- 1950-06-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-408325
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9933
- Coverage period
- 2021-02-01 to 2026-01-23
- Deductible
- $1,815.26 of $3,500.0052%
- Out-of-pocket maximum
- $2,261.00 of $14,000.0016%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3512889619
- Network
- In network
- Rendering NPI
- 9185458301
- Location
- Houston, TX · TIN 72-6037041
- 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 | $334.00 | $207.08 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1 | $166.00 | $102.92 | — | — | DeniedCO27 |
| Totals | $500.00 | $310.00 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-584264
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-003991 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-31 is after coverage terminated on 2026-01-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Unity Primary Care Associates (3512889619). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Primary Care Associates2026-08-31 12:36
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-09-12 03:33
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-31 is after coverage terminated on 2026-01-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002011 | 2026-09-10 | Desert Reference Lab | $103.00 | Denied |
| CLM-2026-034137 | 2026-01-20 | Valley Reference Lab | $156.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.