CLM-2026-021220
Valley Medical Group, Family Medicine. Service 2026-09-18 at office (POS 11). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Santiago Allen
- Member ID
- UHC-39555-75
- Date of birth
- 1975-09-04
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-423026
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8952
- Coverage period
- 2025-09-01 to present
- Deductible
- $884.18 of $1,000.0088%
- Out-of-pocket maximum
- $1,170.84 of $4,000.0029%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5938488512
- Network
- In network
- Rendering NPI
- 3368749388
- Location
- Tempe, AZ · TIN 76-2268417
- 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 | $239.00 | $148.18 | — | — | Review |
| 2 | 90471 | Immunization administration | 59 | 1 | 1 | $25.00 | $15.50 | — | — | Review |
| Totals | $264.00 | $163.68 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-638438
- 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-026284 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-18: SELECT-EPO (EPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 7 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 Valley Medical Group (5938488512). | |
| 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: Valley Medical Group2026-09-18 16:33
Patient seen for encounter for general adult medical examination without abnormal findings. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-09-25 03:12
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-638438.pdf22 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023059 | 2026-03-31 | Summit Community Hospital | $2,610.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.