CLM-2026-025852
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-09-20 to 2026-09-24 at inpatient hospital (POS 21). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Karen Rodriguez
- Member ID
- UHC-78012-31
- Date of birth
- 1984-06-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-426474
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5718
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,062.93 of $2,500.0043%
- Out-of-pocket maximum
- $429.49 of $10,000.004%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 2506967159
- Location
- Denver, CO · TIN 43-9760539
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $187.00 | $84.15 | — | — | DeniedCO204 |
| Totals | $187.00 | $84.15 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-832348
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-20 to 2026-09-21
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036060 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-20: CORE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 16 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 Associates2026-09-24 16:08
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-10 06:27
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
- Itemized billitemized_PA-832348.pdf8 pages
Itemised statement totalling $187.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider 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
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.