CLM-2026-024066
Unity Family Practice, Family Medicine. Service 2026-03-13 at office (POS 11). Received 2026-04-22.
Member
Resolved through the identity graph
- Member
- Christina Meyer
- Member ID
- UHC-19804-16
- Date of birth
- 1955-03-22
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-403112
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1181
- Coverage period
- 2025-09-01 to 2026-02-23
- Deductible
- $1,054.08 of $2,500.0042%
- Out-of-pocket maximum
- $1,630.52 of $10,000.0016%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1322196548
- Network
- In network
- Rendering NPI
- 5817376580
- Location
- Atlanta, GA · TIN 29-1244734
- 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 | $245.00 | $151.90 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $263.00 | $163.06 | — | — | DeniedCO27 |
| Totals | $508.00 | $314.96 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-214138
- 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-027152 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-13 is after coverage terminated on 2026-02-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 | Pass | In-network provider Unity Family Practice (1322196548). | |
| 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 Family Practice2026-03-13 15:58
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-04-22 03:37
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-22 16:05
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-13 is after coverage terminated on 2026-02-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018506 | 2026-04-23 | Canyon Cardiovascular Associates | $8,058.00 | 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
Service after coverage termination.