CLM-2026-021523
Riverside Digestive Health Center, Gastroenterology. Service 2026-04-01 at office (POS 11). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Richard Boyd
- Member ID
- UHC-94105-73
- Date of birth
- 1957-09-01
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-419341
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4415
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,958.16 of $2,500.0078%
- Out-of-pocket maximum
- $2,634.54 of $7,500.0035%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 3886393438
- Location
- Tempe, AZ · TIN 41-1081863
- 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 | $321.00 | $199.02 | — | — | DeniedCO29 |
| Totals | $321.00 | $199.02 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-659949
- 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-004511 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-01: OPTIONS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Fail | CO29 | Received 168 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Digestive Health Center (8834777772). | |
| 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: Riverside Digestive Health Center2026-04-01 17:30
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-09-16 06:20
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-16 10:48
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 engineDenied2026-10-21 13:43Timely filing: Received 168 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015485 | 2026-03-28 | Riverside Imaging Center | $2,604.00 | Approved |
| CLM-2026-030316 | 2025-12-22 | Unity Community Hospital | $2,566.00 | 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
Received after the timely-filing limit.