CLM-2026-024525
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-05-30 at office (POS 11). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Mei Wilson
- Member ID
- UHC-28950-12
- Date of birth
- 1978-03-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-417098
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2022-09-01 to present
- Deductible
- $934.62 of $1,500.0062%
- Out-of-pocket maximum
- $356.37 of $3,000.0012%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 8477690704
- Location
- Denver, CO · TIN 43-9760539
- Authorisation / referral
- none / REF328123
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $108.00 | $48.60 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $349.00 | $157.05 | — | — | DeniedCO204 |
| Totals | $457.00 | $205.65 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-686848
- 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-015351 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-30: CORE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 7 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 Associates2026-05-30 11:59
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-06 01:20
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 engineDenied2026-10-22 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-2026-033510 | 2026-08-26 | Lakeside Skin Care Associates | $261.00 | Approved |
| CLM-2026-033154 | 2026-01-10 | Sunrise Medical Group | $245.00 | 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.