CLM-2026-016250
Riverside Medical Group, Family Medicine. Service 2026-05-25 at office (POS 11). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Kahtryn Li
- Member ID
- UHC-88833-99
- Date of birth
- 1941-01-12
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-420314
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group -
- Coverage period
- 2022-11-01 to 2026-06-07
- Deductible
- $219.06 of $500.0044%
- Out-of-pocket maximum
- $303.63 of $1,000.0030%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5595198842
- Network
- In network
- Rendering NPI
- 5163667947
- Location
- Atlanta, GA · TIN 63-8906521
- 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 | $218.00 | $135.16 | — | — | DeniedCO18 |
| Totals | $218.00 | $135.16 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-824480
- 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-027306 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-25: CHOICE-PLUS-PPO (PPO), effective 2022-11-01, terms 2026-06-07. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016249: 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 Medical Group (5595198842). | |
| 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 Medical Group2026-05-25 14:05
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-07-09 06:43
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-016249: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016249 | 2026-05-25 | Riverside Medical Group | $218.00 | 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.