CLM-2026-032410
Valley Medical Group, Internal Medicine. Service 2026-09-06 at office (POS 11). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Brittany Torres
- Member ID
- UHC-61986-06
- Date of birth
- 1969-12-15
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432332
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8109
- Coverage period
- 2022-05-01 to present
- Deductible
- $170.32 of $2,500.007%
- Out-of-pocket maximum
- $1,495.46 of $5,000.0030%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 7587775132
- Location
- Nashville, TN · TIN 16-4753822
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $115.00 | $71.30 | $30.00 | $41.30 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $314.00 | $194.68 | $0.00 | $194.68 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $65.00 | $40.30 | $0.00 | $40.30 | Paid |
| Totals | $494.00 | $306.28 | $30.00 | $276.28 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-453252
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015931 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-06: SELECT-EPO (EPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 21 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 Valley Medical Group (1946396904). | |
| 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 Medical Group2026-09-06 16:58
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.