CLM-2026-028121
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-06-01 at office (POS 11). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Melissa Garratt
- Member ID
- UHC-66082-81
- Date of birth
- 1953-04-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431012
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group N/A
- Coverage period
- 2021-08-01 to present
- Deductible
- $209.41 of $1,000.0021%
- Out-of-pocket maximum
- $818.16 of $3,000.0027%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 6127415498
- Location
- Miami, FL · TIN 62-7720434
- Authorisation / referral
- none / REF119725
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $256.00 | $158.72 | $40.00 | $118.72 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $341.00 | $211.42 | $0.00 | $211.42 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $41.00 | $25.42 | $0.00 | $25.42 | Paid |
| Totals | $638.00 | $395.56 | $40.00 | $355.56 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-525702
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008896 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-01: CORE-HMO (HMO), effective 2021-08-01. | |
| Timely filing | Pass | Received 11 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 Internal Medicine Associates (5379926517). | |
| 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 Internal Medicine Associates2026-06-01 15:18
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020619 | 2026-09-20 | Meadow Clinical Laboratories | $50.00 | Approved |
| CLM-2026-011253 | 2026-09-14 | Harbor Family Practice | $13.00 | Approved |
| CLM-2026-011295 | 2025-12-21 | Summit Counseling Center | $267.00 | 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.