CLM-2026-024926
Riverside Primary Care Associates, Family Medicine. Service 2026-06-26 at office (POS 11). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Olivia Walker
- Member ID
- none on golden record
- Date of birth
- 1967-04-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404534
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-5519
- Coverage period
- 2021-01-01 to present
- Deductible
- $696.01 of $2,500.0028%
- Out-of-pocket maximum
- $1,583.90 of $7,500.0021%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6269804525
- Network
- In network
- Rendering NPI
- 4157126101
- Location
- Los Angeles, CA · TIN 64-8796526
- 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 | 36415 | Venipuncture | — | 1 | 1 | $13.00 | $8.06 | — | — | PendedIDQ |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $196.00 | $121.52 | — | — | PendedIDQ |
| Totals | $209.00 | $129.58 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-641049
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001395; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-26: SELECT-EPO (EPO), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 38 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 Riverside Primary Care Associates (6269804525). | |
| 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 Primary Care Associates2026-06-26 15:05
Patient seen for encounter for general adult medical examination without abnormal findings.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001395; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-26: SELECT-EPO (EPO), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.