CLM-2026-022563
Unity Primary Care Associates, Family Medicine. Service 2026-03-27 at office (POS 11). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Brittany Sandoval
- Member ID
- UHC-22787-33
- Date of birth
- 1970-02-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-423269
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0624
- Coverage period
- 2024-01-01 to present
- Deductible
- $462.68 of $1,000.0046%
- Out-of-pocket maximum
- $3.68 of $2,000.000%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8618575491
- Network
- In network
- Rendering NPI
- 9565021968
- Location
- San Diego, CA · TIN 48-6444371
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $248.00 | $153.76 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $319.00 | $197.78 | — | — | DeniedCO18 |
| Totals | $567.00 | $351.54 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-778935
- 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-028436 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-27: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 61 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-022562: 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 Unity Primary Care Associates (8618575491). | |
| 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: Unity Primary Care Associates2026-03-27 18:55
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-05-27 02:34
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-022562: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022562 | 2026-03-27 | Unity Primary Care Associates | $567.00 | Approved |
| CLM-2026-003543 | 2026-03-18 | Meadow Medical Group | $336.00 | 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.