CLM-2026-018524
Unity Primary Care Associates, Family Medicine. Service 2026-06-11 at office (POS 11). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Becky Bryant
- Member ID
- UHC-10107-56
- Date of birth
- 1985-07-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411116
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9246
- Coverage period
- 2025-03-01 to 2026-05-23
- Deductible
- $833.40 of $1,500.0056%
- Out-of-pocket maximum
- $1,040.85 of $4,500.0023%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8247321622
- Network
- Out of network
- Rendering NPI
- 4897236319
- Location
- Tempe, AZ · TIN 17-5198361
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $269.00 | $121.05 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $156.00 | $70.20 | — | — | DeniedCO27 |
| Totals | $425.00 | $191.25 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-525833
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021756 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-05-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 8247321622 is out of network and the HMO 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: Unity Primary Care Associates2026-06-11 13:04
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-09 02:41
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-11 is after coverage terminated on 2026-05-23. Provider network: Billing provider 8247321622 is out of network and the HMO 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
Service after coverage termination.