CLM-2026-023029
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-06-30 at office (POS 11). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Lucia Washington
- Member ID
- UHC-13607-07
- Date of birth
- 1972-06-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422760
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9046
- Coverage period
- 2023-09-01 to present
- Deductible
- $903.57 of $1,500.0060%
- Out-of-pocket maximum
- $1,914.57 of $6,000.0032%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 6701543491
- Location
- Denver, CO · TIN 43-9760539
- Authorisation / referral
- none / REF519296
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $217.00 | $97.65 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $291.00 | $130.95 | — | — | DeniedCO204 |
| Totals | $508.00 | $228.60 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-535778
- 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-023555 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-30: NAVIGATE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Pass | Received 23 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 9956855107 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: Riverside Internal Medicine Associates2026-06-30 11:14
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-23 00:41
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-23 16:52
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 engineDenied2026-10-22 12:44Provider network: Billing provider 9956855107 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-2026-021944 | 2026-07-08 | Harbor Clinical Laboratories | $43.00 | Approved |
| CLM-2026-007804 | 2026-03-18 | Harbor Clinical Laboratories | $74.00 | Denied |
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.