CLM-2026-031643
Valley Primary Care Associates, Family Medicine. Service 2026-05-31 at office (POS 11). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Ruth Ortiz
- Member ID
- UHC-29847-48
- Date of birth
- 1990-11-22
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-427754
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2148
- Coverage period
- 2025-06-01 to present
- Deductible
- $430.55 of $1,000.0043%
- Out-of-pocket maximum
- $148.02 of $2,000.007%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 3937782522
- Location
- Denver, CO · TIN 69-3521502
- 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 | $298.00 | $134.10 | — | — | DeniedCO204 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $250.00 | $112.50 | — | — | DeniedCO204 |
| Totals | $548.00 | $246.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-873506
- 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-005961 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-31: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| 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 | Fail | CO204 | Billing provider 6179468650 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: Valley Primary Care Associates2026-05-31 18:15
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-09 02:50
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-09 10:11
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 engineDenied2026-10-22 12:44Provider network: Billing provider 6179468650 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.