CLM-2026-018003
Valley Primary Care Associates, Family Medicine. Service 2026-06-30 at office (POS 11). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Amy Sandoval
- Member ID
- UHC-15452-48
- Date of birth
- 1978-01-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413656
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7897
- Coverage period
- 2023-02-01 to 2026-08-25
- Deductible
- $1,350.65 of $3,500.0039%
- Out-of-pocket maximum
- $1,812.07 of $7,000.0026%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 2944610916
- Location
- Denver, CO · TIN 69-3521502
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $214.00 | $96.30 | — | — | DeniedCO204 |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $29.00 | $13.05 | — | — | DeniedCO204 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $261.00 | $117.45 | — | — | DeniedCO204 |
| Totals | $504.00 | $226.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-583897
- 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-041406 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-30: SELECT-EPO (EPO), effective 2023-02-01, terms 2026-08-25. | |
| Timely filing | Pass | Received 44 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 | Fail | CO204 | Billing provider 6179468650 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Primary Care Associates2026-06-30 16:01
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-08-13 05:30
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-13 11:23
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 6179468650 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.