CLM-2026-022140
Riverside Primary Care Associates, Family Medicine. Service 2026-09-17 at office (POS 11). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Paul White
- Member ID
- UHC-79899-25
- Date of birth
- 1995-03-22
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-418703
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0726
- Coverage period
- 2023-11-01 to present
- Deductible
- $1,369.68 of $2,500.0055%
- Out-of-pocket maximum
- $3,356.87 of $10,000.0034%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8662496362
- Network
- In network
- Rendering NPI
- 9883618156
- Location
- Austin, TX · TIN 71-8699033
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $148.00 | $91.76 | — | — | DeniedCO18 |
| Totals | $148.00 | $91.76 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-584893
- 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-027170 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-17: NAVIGATE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-022139: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (8662496362). | |
| 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 Associates2026-09-17 16:46
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-30 05:46
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-30 13:24
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 13:43Duplicate check: Exact duplicate of CLM-2026-022139: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022139 | 2026-09-17 | Riverside Primary Care Associates | $148.00 | 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
Exact duplicate of an earlier submission.