CLM-2026-021381
Valley Family Practice, Family Medicine. Service 2026-05-16 at office (POS 11). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Stephen King
- Member ID
- UHC-15796-58
- Date of birth
- 1969-01-20
- Identity
- Verified6 records, confidence 0.88
- Claim record
- CLMCLM-429483
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2317
- Coverage period
- 2022-03-01 to 2026-04-12
- Deductible
- $55.29 of $2,500.002%
- Out-of-pocket maximum
- $2,950.93 of $10,000.0030%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 4588025997
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $225.00 | $139.50 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $35.00 | $21.70 | — | — | DeniedCO27 |
| Totals | $260.00 | $161.20 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-383876
- 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-002628 (verified, link confidence 0.88). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-16 is after coverage terminated on 2026-04-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 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 Practice2026-05-16 13:53
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-26 04:36
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-26 12:58
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-16 is after coverage terminated on 2026-04-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032671 | 2026-03-13 | Desert Cardiovascular Associates | $1,374.00 | Denied |
| CLM-2026-008559 | 2026-07-13 | Summit Community Hospital | $3,052.00 | Denied |
| CLM-2026-021543 | 2025-12-11 | Meadow Clinical Laboratories | $99.00 | Approved |
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.