CLM-2026-016323
Unity Family Practice, Family Medicine. Service 2026-09-15 at office (POS 11). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Eugene Campbell
- Member ID
- UHC-94513-70
- Date of birth
- 1951-03-21
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400345
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8102
- Coverage period
- 2022-05-01 to 2026-03-25
- Deductible
- $1,793.11 of $3,500.0051%
- Out-of-pocket maximum
- $4,862.34 of $14,000.0035%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1322196548
- Network
- In network
- Rendering NPI
- 6040588959
- Location
- Atlanta, GA · TIN 29-1244734
- 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 | $24.00 | $14.88 | — | — | DeniedCO27 |
| Totals | $24.00 | $14.88 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-892815
- 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-010426 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-15 is after coverage terminated on 2026-03-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 Family Practice (1322196548). | |
| 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 Family Practice2026-09-15 18:55
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-26 05:56
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-15 is after coverage terminated on 2026-03-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018625 | 2026-03-20 | Canyon Internal Medicine Associates | $74.00 | Denied |
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.