CLM-2026-021963
Riverside Primary Care Associates, Family Medicine. Service 2026-04-27 at office (POS 11). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Gary Weber
- Member ID
- UHC-46874-68
- Date of birth
- 1981-03-13
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-403693
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8955
- Coverage period
- 2025-05-01 to present
- Deductible
- $633.56 of $3,500.0018%
- Out-of-pocket maximum
- $3,259.27 of $10,500.0031%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3508653433
- Network
- In network
- Rendering NPI
- 7547617655
- Location
- Nashville, TN · TIN 89-3003257
- 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 | $9.30 | $0.00 | Paid |
| Totals | $15.00 | $9.30 | $9.30 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-430299
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001713 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-27: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 31 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 Riverside Primary Care Associates (3508653433). | |
| 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 Primary Care Associates2026-04-27 16:36
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021964 | 2026-04-27 | Riverside Primary Care Associates | $15.00 | Needs review |
| CLM-2026-034108 | 2026-01-05 | Evergreen Primary Care Associates | $246.00 | Approved |
| CLM-2026-030693 | 2025-11-24 | Harbor Medical Group | $215.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.