CLM-2026-029694
Riverside Family Practice, Family Medicine. Service 2026-08-08 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Shirley Adams
- Member ID
- UHC-91288-40
- Date of birth
- 1972-07-20
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-414684
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5862
- Coverage period
- 2025-06-01 to 2026-01-05
- Deductible
- $1,069.73 of $2,500.0043%
- Out-of-pocket maximum
- $913.22 of $5,000.0018%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1193895335
- Network
- In network
- Rendering NPI
- 5113401876
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $219.00 | $135.78 | — | — | DeniedCO27 |
| Totals | $219.00 | $135.78 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-959123
- 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-003740 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-08 is after coverage terminated on 2026-01-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Family Practice2026-08-08 12:34
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-09-17 00:44
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-17 11:56
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-08 is after coverage terminated on 2026-01-05.
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.