CLM-2026-026668
Riverside Family Practice, Family Medicine. Service 2025-12-11 at office (POS 11). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Alexander Hunt
- Member ID
- UHC-71385-53
- Date of birth
- 2003-02-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406778
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9603
- Coverage period
- 2022-03-01 to present
- Deductible
- $399.70 of $1,000.0040%
- Out-of-pocket maximum
- $776.16 of $2,000.0039%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1193895335
- Network
- In network
- Rendering NPI
- 5603175584
- Location
- Los Angeles, CA · TIN 66-7778652
- 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 | $175.00 | $108.50 | — | — | Review |
| Totals | $175.00 | $108.50 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-470857
- 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-000429 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-11: OPTIONS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 22 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 Family Practice (1193895335). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for acute upper respiratory infection, unspecified. Note dictated; signature ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Family Practice2025-12-11 13:59
Patient seen for acute upper respiratory infection, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-02 02:13
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-02 13:24
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for acute upper respiratory infection, unspecified. Note dictated; signature ”.
- AI recommendationPended2026-10-21 14:05The claim is pended due to incomplete documentation. The clinical note is missing the provider's signature, as indicated by the system note [N2]. A development letter has been sent to the provider to obtain the missing signature. Once the signature is obtained and the documentation is complete, the claim can be re-evaluated for approval.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · c4d706ff
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note is missing the provider's signature, as indicated by the system note [N2]. A development letter has been sent to the provider to obtain the missing signature. Once the signature is obtained and the documentation is complete, the claim can be re-evaluated for approval.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.