CLM-2026-025730
Unity Primary Care Associates, Family Medicine. Service 2026-07-26 at office (POS 11). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Barbara Fox
- Member ID
- UHC-19091-69
- Date of birth
- 1964-06-23
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412856
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5465
- Coverage period
- 2024-02-01 to present
- Deductible
- $579.65 of $1,000.0058%
- Out-of-pocket maximum
- $548.38 of $2,000.0027%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8618575491
- Network
- In network
- Rendering NPI
- 2316570607
- Location
- San Diego, CA · TIN 48-6444371
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $152.00 | $94.24 | $40.00 | $54.24 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $182.00 | $112.84 | $0.00 | $112.84 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1,2 | $14.00 | $8.68 | $0.00 | $8.68 | Paid |
| Totals | $348.00 | $215.76 | $40.00 | $175.76 | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-389724
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013948 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-26: NULL (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 41 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 Primary Care Associates (8618575491). | |
| 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 Primary Care Associates2026-07-26 15:03
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-05 01:35
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-05 08:52
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-389724.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.