CLM-2026-017075
Unity Medical Group, Internal Medicine. Service 2025-12-22 at office (POS 11). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Doris Wright
- Member ID
- UHC-04572-43
- Date of birth
- 1960-06-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415136
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4527
- Coverage period
- 2023-10-01 to present
- Deductible
- $206.63 of $500.0041%
- Out-of-pocket maximum
- $112.87 of $2,000.006%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 7221073316
- Location
- Mesa, AZ · TIN 43-9161942
- 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 | 59 | 1 | 1 | $232.00 | $143.84 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 2 | $295.00 | $182.90 | — | — | Review |
| Totals | $527.00 | $326.74 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-297623
- 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-001219 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: CHOICE-PLUS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 13 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 Medical Group (1355996814). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2025-12-22 11:19
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-04 02:50
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-04 12:02
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-297623.pdf11 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:05The claim includes two office visits (99214 and 99215) billed with modifier 59, which is used to indicate a distinct procedural service. However, the clinical note [N1] and the medical record [A1] both indicate that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59 and results in a bundling issue as per NCCI rules [N2]. Therefore, the claim is denied for CO97 - Benefit included in another service already adjudicated.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 4c671e4d
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004034 | 2026-01-16 | Riverside Family Practice | $42.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes two office visits (99214 and 99215) billed with modifier 59, which is used to indicate a distinct procedural service. However, the clinical note [N1] and the medical record [A1] both indicate that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59 and results in a bundling issue as per NCCI rules [N2]. Therefore, the claim is denied for CO97 - Benefit included in another service already adjudicated.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.