CLM-2026-032506
Valley Primary Care Associates, Family Medicine. Service 2026-05-31 at office (POS 11). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Carolyn Evans
- Member ID
- UHC-34615-37
- Date of birth
- 1980-01-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423217
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1688
- Coverage period
- 2022-07-01 to 2026-05-04
- Deductible
- $465.50 of $1,000.0047%
- Out-of-pocket maximum
- $519.77 of $2,000.0026%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7442240793
- Network
- In network
- Rendering NPI
- 9171657478
- Location
- Scottsdale, AZ · TIN 22-1174857
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $245.00 | $151.90 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 2 | $257.00 | $159.34 | — | — | DeniedCO27 |
| Totals | $502.00 | $311.24 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-783252
- 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-034660 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-31 is after coverage terminated on 2026-05-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Primary Care Associates (7442240793). | |
| 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 09:13
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-12 06:04
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-12 10:35
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 12:44Eligibility: Date of service 2026-05-31 is after coverage terminated on 2026-05-04.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022647 | 2026-06-14 | Unity Imaging Center | $157.00 | 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.