CLM-2026-022953
Valley Primary Care Associates, Family Medicine. Service 2026-03-02 at office (POS 11). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Frank Thompson
- Member ID
- UHC-37893-53
- Date of birth
- 1992-04-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403581
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0825
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,326.61 of $2,500.0053%
- Out-of-pocket maximum
- $1,047.76 of $5,000.0021%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 6933534672
- Location
- Denver, CO · TIN 69-3521502
- 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 | $230.00 | $103.50 | — | — | DeniedCO204 |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $39.00 | $17.55 | — | — | DeniedCO204 |
| Totals | $269.00 | $121.05 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-281673
- 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-010177 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-02: NAVIGATE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 5 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 | Fail | CO204 | Billing provider 6179468650 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Primary Care Associates2026-03-02 15:31
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-03-07 02:50
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 6179468650 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025036 | 2026-09-15 | Canyon Clinical Laboratories | $152.00 | Approved |
| CLM-2026-004829 | 2025-12-29 | Cornerstone Imaging Center | $3,384.00 | 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
No out-of-network benefit on this plan.