CLM-2026-032642
Valley Medical Group, Family Medicine. Service 2026-05-08 at office (POS 11). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Priya Henry
- Member ID
- UHC-78896-26
- Date of birth
- 1997-12-11
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-412223
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1640
- Coverage period
- 2025-01-01 to present
- Deductible
- $732.51 of $1,000.0073%
- Out-of-pocket maximum
- $1,524.24 of $4,000.0038%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5938488512
- Network
- In network
- Rendering NPI
- 8440879814
- Location
- Tempe, AZ · TIN 76-2268417
- 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 | $255.00 | $158.10 | $25.00 | $133.10 | Paid |
| Totals | $255.00 | $158.10 | $25.00 | $133.10 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-437752
- 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-029030 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-08: NAVIGATE-HMO (HMO), effective 2025-01-01. | |
| 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 Valley Medical Group (5938488512). | |
| 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 Group2026-05-08 12:04
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-27 01:15
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-437752.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017410 | 2026-08-13 | Desert Imaging Center | $1,960.00 | Needs review |
| CLM-2026-032808 | 2026-07-16 | Valley Internal Medicine Associates | $172.00 | Approved |
| CLM-2026-007092 | 2026-04-13 | Heritage Community Hospital | $3,155.00 | Approved |
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
Authorisation must be confirmed with UM before payment.