CLM-2026-026188
Desert Primary Care Associates, Family Medicine. Service 2026-06-08 at office (POS 11). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Jack Pena
- Member ID
- UHC-35249-07
- Date of birth
- 2004-03-20
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428994
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1162
- Coverage period
- 2023-09-01 to 2026-01-06
- Deductible
- $100.61 of $1,500.007%
- Out-of-pocket maximum
- $2,058.03 of $6,000.0034%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6762345471
- Network
- In network
- Rendering NPI
- 1813049669
- Location
- Dallas, TX · TIN 75-4232082
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $235.00 | $145.70 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $22.00 | $13.64 | — | — | DeniedCO27 |
| Totals | $257.00 | $159.34 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-976837
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-000992 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-08 is after coverage terminated on 2026-01-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Desert Primary Care Associates (6762345471). | |
| 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: Desert Primary Care Associates2026-06-08 12:51
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-06-29 05:17
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-08 is after coverage terminated on 2026-01-06.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025271 | 2026-07-23 | Riverside Primary Care Associates | $2,722.00 | Denied |
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
Service after coverage termination.