CLM-2026-030628
Desert Primary Care Associates, Family Medicine. Service 2026-03-09 at office (POS 11). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Jennifer Medina
- Member ID
- UHC-07728-57
- Date of birth
- 2000-06-27
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-423970
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3613
- Coverage period
- 2022-07-01 to present
- Deductible
- $478.91 of $1,500.0032%
- Out-of-pocket maximum
- $2,097.30 of $4,500.0047%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8080835506
- Network
- In network
- Rendering NPI
- 8385936892
- Location
- Denver, CO · TIN 39-5381376
- 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 | 90471 | Immunization administration | — | 1 | 1 | $35.00 | $21.70 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $20.00 | $12.40 | — | — | DeniedCO29 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $143.00 | $88.66 | — | — | DeniedCO29 |
| Totals | $198.00 | $122.76 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-114688
- 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-008471 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-09: MEDICARE-ADV-B (MA), effective 2022-07-01. | |
| Timely filing | Fail | CO29 | Received 129 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Primary Care Associates (8080835506). | |
| 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: Desert Primary Care Associates2026-03-09 14:31
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-16 00:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 129 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000525 | 2026-02-28 | Harbor Medical Group | $200.00 | 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
Received after the timely-filing limit.