CLM-2026-025900
Riverside Primary Care Associates, Family Medicine. Service 2026-06-09 at office (POS 11). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Cheryl McDonald
- Member ID
- UHC-70707-57
- Date of birth
- 1962-10-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400871
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3246
- Coverage period
- 2024-10-01 to present
- Deductible
- $1,184.95 of $1,500.0079%
- Out-of-pocket maximum
- $763.97 of $4,500.0017%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3508653433
- Network
- In network
- Rendering NPI
- 6919914161
- Location
- Nashville, TN · TIN 89-3003257
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $203.00 | $125.86 | $30.00 | $95.86 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $27.00 | $16.74 | $0.00 | $16.74 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $308.00 | $190.96 | $0.00 | $190.96 | Paid |
| Totals | $538.00 | $333.56 | $30.00 | $303.56 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-803230
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024974 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-09: MEDICARE-ADV-B (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 44 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 (3508653433). | |
| 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 Associates2026-06-09 18:02
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033108 | 2026-03-03 | Meadow Regional Medical Center | $1,337.00 | Approved |
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
Clean claim, priced at contract rate.