CLM-2026-016240
Unity Medical Group, Family Medicine. Service 2026-07-09 at office (POS 11). Received 2026-08-11.
Member
Resolved through the identity graph
- Member
- Jack Robertson
- Member ID
- UHC-33762-69
- Date of birth
- 1976-04-13
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429666
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2391
- Coverage period
- 2022-07-01 to present
- Deductible
- $627.06 of $1,500.0042%
- Out-of-pocket maximum
- $400.81 of $3,000.0013%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6749849405
- Network
- In network
- Rendering NPI
- 1413755558
- Location
- Houston, TX · TIN 69-3600999
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | — | — | Review |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $230.00 | $142.60 | — | — | Review |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $218.00 | $135.16 | — | — | Review |
| Totals | $471.00 | $292.02 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-445685
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040710 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-09: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-016239; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Medical Group (6749849405). | |
| 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: Unity Medical Group2026-07-09 15:09
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-08-11 02:31
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-11 16:35
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-016239.pdf1 page
Provider cover letter requesting replacement of CLM-2026-016239.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-016239; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016239 | 2026-07-09 | Unity Medical Group | $471.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.