CLM-2026-019338
Desert Primary Care Associates, Family Medicine. Service 2026-05-02 at office (POS 11). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Marcus Alexander
- Member ID
- UHC-89293-82
- Date of birth
- 1987-11-15
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415924
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8225
- Coverage period
- 2022-02-01 to 2026-05-11
- Deductible
- $278.09 of $1,500.0019%
- Out-of-pocket maximum
- $889.52 of $4,500.0020%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8080835506
- Network
- In network
- Rendering NPI
- 7938587673
- Location
- Denver, CO · TIN 39-5381376
- 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 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $19.22 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $205.00 | $127.10 | — | — | Review |
| Totals | $236.00 | $146.32 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-867905
- 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-015044 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: CORE-HMO (HMO), effective 2022-02-01, terms 2026-05-11. | |
| Timely filing | Pass | Received 14 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 Desert Primary Care Associates (8080835506). | |
| 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: “Established patient presents with encounter for general adult medical examination without ”. 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: Desert Primary Care Associates2026-05-02 10:05
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-16 05:53
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-16 08:36
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with encounter for general adult medical examination without ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014340 | 2026-08-13 | Valley Community Hospital | $174.00 | Denied |
| CLM-2026-007438 | 2026-02-22 | Sunrise Dermatology Clinic | $270.00 | Denied |
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.