CLM-2026-029884
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-05-19 to 2026-05-23 at inpatient hospital (POS 21). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Jennifer Riley
- Member ID
- UHC-53110-32
- Date of birth
- 1988-04-14
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-409584
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6268
- Coverage period
- 2021-09-01 to 2026-04-15
- Deductible
- $402.16 of $500.0080%
- Out-of-pocket maximum
- $166.34 of $1,500.0011%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5379926517
- Network
- In network
- Rendering NPI
- 8492935993
- Location
- Miami, FL · TIN 62-7720434
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $212.00 | $116.60 | — | — | DeniedCO27 |
| Totals | $212.00 | $116.60 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-367880
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-19 to 2026-05-20
- 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-011198 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-19 is after coverage terminated on 2026-04-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 Associates2026-05-23 14:17
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-14 04:45
Attachments
Documents received with the claim
- Itemized billitemized_PA-367880.pdf6 pages
Itemised statement totalling $212.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-19 is after coverage terminated on 2026-04-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017577 | 2026-04-02 | Unity Reference Lab | $99.00 | Approved |
| CLM-2026-002333 | 2025-12-25 | Lakeside Dermatology Clinic | $936.00 | Approved |
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.