CLM-2026-033241
Desert Primary Care Associates, Family Medicine. Service 2026-04-19 at office (POS 11). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Bryan Green
- Member ID
- UHC-72511-86
- Date of birth
- 1995-07-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403483
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0770
- Coverage period
- 2022-05-01 to present
- Deductible
- $416.71 of $500.0083%
- Out-of-pocket maximum
- $463.42 of $1,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6762345471
- Network
- In network
- Rendering NPI
- 3384716866
- Location
- Dallas, TX · TIN 75-4232082
- 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 | $316.00 | $195.92 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $282.00 | $174.84 | — | — | Review |
| 3 | 36415 | Venipuncture | 25 | 1 | 2 | $17.00 | $10.54 | — | — | Review |
| Totals | $615.00 | $381.30 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-146919
- 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-031673 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-19: OPTIONS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-033240, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Primary Care Associates (6762345471). | |
| 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: Desert Primary Care Associates2026-04-19 13:58
Patient seen for type 2 diabetes mellitus without complications. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-09 02:21
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-09 14:53
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 engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-033240, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033240 | 2026-04-19 | Valley Primary Care Associates | $615.00 | 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
Different billing provider; separately payable.