CLM-2026-030474
Riverside Primary Care Associates, Family Medicine. Service 2026-01-25 at office (POS 11). Received 2026-03-19.
Member
Resolved through the identity graph
- Member
- Julia Murphy
- Member ID
- UHC-12257-62
- Date of birth
- 2005-01-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424751
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9416
- Coverage period
- 2025-09-01 to present
- Deductible
- $267.20 of $500.0053%
- Out-of-pocket maximum
- $429.48 of $1,500.0029%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6269804525
- Network
- In network
- Rendering NPI
- 5888125791
- Location
- Los Angeles, CA · TIN 64-8796526
- 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 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $13.64 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $144.00 | $89.28 | — | — | DeniedCO18 |
| Totals | $166.00 | $102.92 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-435644
- 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-018473 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-25: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 53 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030473: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (6269804525). | |
| 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 Associates2026-01-25 15:59
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-03-19 03:53
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-030473: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027116 | 2026-06-03 | Desert Heart Institute | $8,229.00 | Approved |
| CLM-2026-030473 | 2026-01-25 | Riverside Primary Care Associates | $166.00 | 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
Exact duplicate of an earlier submission.