CLM-2026-027976
Unity Primary Care Associates, Family Medicine. Service 2025-12-06 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Aaron Evans
- Member ID
- UHC-69781-33
- Date of birth
- 2005-04-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422568
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0869
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,272.77 of $1,500.0085%
- Out-of-pocket maximum
- $13.39 of $3,000.000%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 2344230497
- Location
- Charlotte, NC · TIN 92-2641302
- 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 | $211.00 | $94.95 | — | — | DeniedCO204 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $237.00 | $106.65 | — | — | DeniedCO204 |
| Totals | $448.00 | $201.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-314963
- 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-002545 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-06: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 33 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 | Fail | CO204 | Billing provider 3636526220 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Unity Primary Care Associates2025-12-06 14:48
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-08 00:57
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-08 14:35
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 engineDenied2026-10-21 13:43Provider network: Billing provider 3636526220 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031859 | 2026-06-04 | Heritage Orthopedic Specialists | $34,250.00 | Needs review |
| CLM-2026-031858 | 2026-06-04 | Lakeside Orthopedic Specialists | $34,250.00 | Needs review |
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
No out-of-network benefit on this plan.