CLM-2026-030657
Unity Primary Care Associates, Family Medicine. Service 2026-07-19 at office (POS 11). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Ana Bell
- Member ID
- UHC-07204-04
- Date of birth
- 2007-05-09
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-427066
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3757
- Coverage period
- 2022-10-01 to 2026-02-08
- Deductible
- $1,290.31 of $1,500.0086%
- Out-of-pocket maximum
- $751.00 of $3,000.0025%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8247321622
- Network
- Out of network
- Rendering NPI
- 9806128986
- Location
- Tempe, AZ · TIN 17-5198361
- 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 | $38.00 | $17.10 | — | — | DeniedCO27 |
| Totals | $38.00 | $17.10 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-595060
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038999 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-19 is after coverage terminated on 2026-02-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 39 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Primary Care Associates2026-07-19 10:56
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-27 03:43
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-19 is after coverage terminated on 2026-02-08. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028862 | 2026-06-14 | Desert Diabetes Center | $613.00 | 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.