CLM-2026-019170
Riverside Primary Care Associates, Family Medicine. Service 2025-11-29 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Jennifer Nguyen
- Member ID
- UHC-98317-01
- Date of birth
- 1985-01-16
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-428829
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4659
- Coverage period
- 2024-10-01 to present
- Deductible
- $311.37 of $1,500.0021%
- Out-of-pocket maximum
- $2,511.07 of $6,000.0042%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 2462414691
- Location
- Phoenix, AZ · TIN 77-3257014
- 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 | 59 | 1 | 1 | $249.00 | $154.38 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $211.00 | $130.82 | — | — | Review |
| Totals | $460.00 | $285.20 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-105042
- 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-002518 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-11-29: CHOICE-PLUS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 40 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 Riverside Primary Care Associates (6920830281). | |
| 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: Riverside Primary Care Associates2025-11-29 16:29
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-08 04:04
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-08 16:21
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-105042.pdf18 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 14:15The claim includes two office visit codes (99203 and 99213) with modifier 59, which are normally bundled. The clinical note [N1] indicates 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, which is only acceptable when the record documents a distinct anatomical site or separate session. Therefore, the claim is denied with reason code CO97 for a benefit included in another service already adjudicated.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 7aabb45d
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009060 | 2026-04-29 | Pinecrest Family Practice | $790.00 | 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 visit codes (99203 and 99213) with modifier 59, which are normally bundled. The clinical note [N1] indicates 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, which is only acceptable when the record documents a distinct anatomical site or separate session. Therefore, the claim is denied with reason code CO97 for a 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.