CLM-2026-029720
Riverside Primary Care Associates, Family Medicine. Service 2026-02-10 at office (POS 11). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Gerald Pena
- Member ID
- UHC-42304-14
- Date of birth
- 1978-10-23
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-412917
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group -
- Coverage period
- 2025-04-01 to 2026-01-22
- Deductible
- $478.90 of $1,500.0032%
- Out-of-pocket maximum
- $202.64 of $3,000.007%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 8697656881
- Location
- Phoenix, AZ · TIN 77-3257014
- 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 | $171.00 | $106.02 | — | — | DeniedCO27 |
| Totals | $171.00 | $106.02 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-706078
- 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-021130 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-10 is after coverage terminated on 2026-01-22. 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 Primary Care Associates (6920830281). | |
| 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 Associates2026-02-10 11:35
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-22 06:15
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 2026-02-10 is after coverage terminated on 2026-01-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029335 | 2026-03-03 | Lakeside Physical Therapy | $299.00 | Denied |
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.