CLM-2026-032217
Riverside Family Practice, Family Medicine. Service 2026-04-12 at office (POS 11). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Danielle Lee
- Member ID
- UHC-50635-73
- Date of birth
- 1975-10-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-422620
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7511
- Coverage period
- 2025-08-01 to present
- Deductible
- $436.21 of $500.0087%
- Out-of-pocket maximum
- $381.95 of $2,000.0019%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1193895335
- Network
- In network
- Rendering NPI
- 2371185622
- Location
- Los Angeles, CA · TIN 66-7778652
- 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 | $309.00 | $191.58 | — | — | Review |
| Totals | $309.00 | $191.58 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-895488
- 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-028626 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-12: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 19 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 | Pass | In-network provider Riverside Family Practice (1193895335). | |
| 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: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”. 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 Family Practice2026-04-12 18:59
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-01 04:27
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-01 13:26
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006335 | 2026-05-24 | Unity Digestive Health Center | $217.00 | Approved |
| CLM-2026-027272 | 2026-05-24 | Harbor Rehabilitation Center | $425.00 | Approved |
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.