CLM-2026-020459
Valley Family Practice, Family Medicine. Service 2026-03-22 at office (POS 11). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Vicctoria Hart
- Member ID
- UHC-02304-58
- Date of birth
- 1976-07-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428525
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group UNKNOWN
- Coverage period
- 2023-01-01 to present
- Deductible
- $448.91 of $2,500.0018%
- Out-of-pocket maximum
- $1,701.26 of $7,500.0023%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 5853489883
- Location
- Houston, TX · TIN 34-3279519
- 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 | 36415 | Venipuncture | — | 1 | 1 | $15.00 | $9.30 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $232.00 | $143.84 | — | — | Review |
| Totals | $247.00 | $153.14 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-902748
- 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-025638 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-22: NULL (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-020458, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Family Practice (3411841638). | |
| 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 Family Practice2026-03-22 17:24
Patient seen for acute upper respiratory infection, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-17 01:18
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-17 15:23
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 engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-020458, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027440 | 2026-03-24 | Mesa Medical Group | $268.00 | Approved |
| CLM-2026-020458 | 2026-03-22 | Evergreen Family Practice | $247.00 | Approved |
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
Different billing provider; separately payable.