CLM-2026-034214
Desert Primary Care Associates, Family Medicine. Service 2026-09-16 at office (POS 11). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Grace Phillips
- Member ID
- UHC-93122-46
- Date of birth
- 1971-09-14
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428160
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3569
- Coverage period
- 2022-12-01 to 2026-07-25
- Deductible
- $100.06 of $500.0020%
- Out-of-pocket maximum
- $592.48 of $2,000.0030%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8080835506
- Network
- In network
- Rendering NPI
- 8160904297
- Location
- Denver, CO · TIN 39-5381376
- 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 | $208.00 | $128.96 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 2 | $297.00 | $184.14 | — | — | DeniedCO27 |
| Totals | $505.00 | $313.10 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-727106
- 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-032294 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-16 is after coverage terminated on 2026-07-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Desert Primary Care Associates (8080835506). | |
| 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 Associates2026-09-16 09:52
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-07 00:59
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-16 is after coverage terminated on 2026-07-25.
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
Service after coverage termination.