CLM-2026-018106
Unity Medical Group, Family Medicine. Service 2025-08-29 at office (POS 11). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Samantha Gibson
- Member ID
- UHC-11351-96
- Date of birth
- 1957-09-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431798
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1705
- Coverage period
- 2021-10-01 to 2026-02-17
- Deductible
- $333.60 of $500.0067%
- Out-of-pocket maximum
- $324.17 of $2,000.0016%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6749849405
- Network
- In network
- Rendering NPI
- 8684497877
- Location
- Houston, TX · TIN 69-3600999
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $185.00 | $114.70 | — | — | DeniedCO29 |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $38.00 | $23.56 | — | — | DeniedCO29 |
| Totals | $223.00 | $138.26 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-118924
- 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-018267 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-08-29: CORE-HMO (HMO), effective 2021-10-01, terms 2026-02-17. | |
| Timely filing | Fail | CO29 | Received 191 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (6749849405). | |
| 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 Medical Group2025-08-29 16:58
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-08 05:15
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-08 09:20
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 191 days after the last date of service (limit 90).
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
Received after the timely-filing limit.