CLM-2026-034167
Unity Primary Care Associates, Family Medicine. Service 2026-04-30 at office (POS 11). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Jesse Reyes
- Member ID
- none on golden record
- Date of birth
- 2007-02-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414229
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 2306265580
- Location
- Charlotte, NC · TIN 92-2641302
- 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 | 90471 | Immunization administration | — | 1 | 1 | $37.00 | $16.65 | — | — | PendedIDQ |
| Totals | $37.00 | $16.65 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-952282
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002223; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 5 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Primary Care Associates2026-04-30 17:33
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-05 03:54
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-05 10:06
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002223; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.