CLM-2026-033507
Riverside Medical Group, Family Medicine. Service 2025-09-10 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Pamela Morrison
- Member ID
- UHC-42829-49
- Date of birth
- 1982-10-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-430800
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0856
- Coverage period
- 2024-07-01 to present
- Deductible
- $272.59 of $1,500.0018%
- Out-of-pocket maximum
- $2,883.79 of $6,000.0048%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8250558730
- Network
- In network
- Rendering NPI
- 6661301450
- Location
- Nashville, TN · TIN 54-5227365
- 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 | $237.00 | $146.94 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $24.00 | $14.88 | — | — | DeniedCO29 |
| Totals | $261.00 | $161.82 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-582179
- 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-026153 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-10: MEDICARE-ADV-B (MA), effective 2024-07-01. | |
| Timely filing | Fail | CO29 | Received 218 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Medical Group (8250558730). | |
| 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: Riverside Medical Group2025-09-10 17:36
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-16 03:22
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 218 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.