CLM-2026-031116
Unity Primary Care Associates, Family Medicine. Service 2026-09-13 at office (POS 11). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Zachary Schultz
- Member ID
- UHC-17530-09
- Date of birth
- 1966-05-06
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-426209
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8994
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,226.52 of $2,500.0049%
- Out-of-pocket maximum
- $1,076.75 of $7,500.0014%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 6410324373
- Location
- Charlotte, NC · TIN 92-2641302
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $325.00 | $146.25 | — | — | DeniedCO204 |
| Totals | $325.00 | $146.25 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-578217
- 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-027274 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-13: CORE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 20 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 | Fail | CO204 | Billing provider 3636526220 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-09-13 16:35
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-03 00:30
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3636526220 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.