CLM-2026-030596
Riverside Internal Medicine Associates, Internal Medicine. Service 2026-05-02 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Lucia Guerrero
- Member ID
- none on golden record
- Date of birth
- 2006-03-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425355
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4995
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,191.04 of $1,500.0079%
- Out-of-pocket maximum
- $86.02 of $3,000.003%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9956855107
- Network
- Out of network
- Rendering NPI
- 5928833396
- Location
- Denver, CO · TIN 43-9760539
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $347.00 | $156.15 | — | — | PendedIDQ |
| Totals | $347.00 | $156.15 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-565134
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 4 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001511; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-02: N/A (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for copd, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Internal Medicine Associates2026-05-02 11:05
Patient seen for copd, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-11 02:57
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-11 14:23
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001511; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-02: N/A (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Patient seen for copd, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.