CLM-2026-017762
Valley Medical Group, Internal Medicine. Service 2026-07-27 at office (POS 11). Received 2026-09-01.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7401
- Coverage period
- 2021-02-01 to present
- Deductible
- $81.07 of $1,000.008%
- Out-of-pocket maximum
- $545.96 of $3,000.0018%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 3221799588
- Location
- Nashville, TN · TIN 16-4753822
- Authorisation / referral
- none / REF154878
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 | $261.00 | $161.82 | — | — | PendedCO16 |
| Totals | $261.00 | $161.82 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-682943
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-07-27: NAVIGATE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 36 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 Valley Medical Group (1946396904). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Medical Group2026-07-27 17:18
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-01 03:11
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. Completeness: Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.