CLM-2026-027169
Riverside Primary Care Associates, Family Medicine. Service 2026-02-11 at office (POS 11). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Teresa Tran
- Member ID
- UHC-44901-09
- Date of birth
- 1997-11-01
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-403318
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9670
- Coverage period
- 2023-06-01 to 2026-02-06
- Deductible
- $1,418.75 of $2,500.0057%
- Out-of-pocket maximum
- $1,071.88 of $7,500.0014%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8662496362
- Network
- In network
- Rendering NPI
- 2113346391
- Location
- Austin, TX · TIN 71-8699033
- 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 | $187.00 | $115.94 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $320.00 | $198.40 | — | — | DeniedCO27 |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $16.00 | $9.92 | — | — | DeniedCO27 |
| Totals | $523.00 | $324.26 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-825454
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018562 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-11 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 (8662496362). | |
| 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 Associates2026-02-11 17:59
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-09 04:16
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-11 is after coverage terminated on 2026-02-06.
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
Service after coverage termination.