CLM-2026-027228
Valley Primary Care Associates, Family Medicine. Service 2026-06-04 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Christina Austin
- Member ID
- UHC-18686-11
- Date of birth
- 1968-05-12
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-404182
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8110
- Coverage period
- 2021-01-01 to present
- Deductible
- $844.93 of $1,500.0056%
- Out-of-pocket maximum
- $2,378.55 of $6,000.0040%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7442240793
- Network
- In network
- Rendering NPI
- 4124113398
- Location
- Scottsdale, AZ · TIN 22-1174857
- 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 | 36415 | Venipuncture | — | 1 | 1 | $25.00 | $15.50 | $15.50 | $0.00 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $45.00 | $27.90 | $0.00 | $27.90 | Paid |
| Totals | $70.00 | $43.40 | $15.50 | $27.90 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-444068
- 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-019313 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-04: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 7 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 Valley Primary Care Associates (7442240793). | |
| 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: Valley Primary Care Associates2026-06-04 16:46
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-2026-010025 | 2026-03-11 | Harbor Primary Care Associates | $197.00 | 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.