CLM-2026-022169
Desert Primary Care Associates, Family Medicine. Service 2025-08-12 at office (POS 11). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Peter Romero
- Member ID
- UHC-20964-03
- Date of birth
- 1972-03-01
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-421294
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3372
- Coverage period
- 2022-08-01 to present
- Deductible
- $398.41 of $500.0080%
- Out-of-pocket maximum
- $308.28 of $1,500.0021%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7395503999
- Network
- In network
- Rendering NPI
- 7267649698
- Location
- Nashville, TN · TIN 82-5411233
- 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 | 90471 | Immunization administration | — | 1 | 1 | $45.00 | $27.90 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $315.00 | $195.30 | — | — | DeniedCO29 |
| 3 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1,2 | $194.00 | $120.28 | — | — | DeniedCO29 |
| Totals | $554.00 | $343.48 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-766705
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017495 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-08-12: OPTIONS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Fail | CO29 | Received 204 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 Desert Primary Care Associates (7395503999). | |
| 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: Desert Primary Care Associates2025-08-12 17:11
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-03-04 05:36
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 204 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.