CLM-2026-034551
Desert Family Practice, Family Medicine. Service 2026-06-04 at office (POS 11). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Mariana Porter
- Member ID
- UHC-32514-31
- Date of birth
- 1999-10-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410521
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0862
- Coverage period
- 2024-12-01 to present
- Deductible
- $808.51 of $1,000.0081%
- Out-of-pocket maximum
- $562.63 of $2,000.0028%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8144042321
- Network
- In network
- Rendering NPI
- 4236876155
- Location
- Miami, FL · TIN 86-4678898
- 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 | 36415 | Venipuncture | 59 | 1 | 1 | $21.00 | $13.02 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1,2 | $196.00 | $121.52 | — | — | Review |
| Totals | $217.00 | $134.54 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-895580
- 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-038283 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-04: CHOICE-PLUS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 39 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 Family Practice (8144042321). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Family Practice2026-06-04 12:18
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-07-13 06:35
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-895580.pdf4 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Modifier 59 supported: distinct anatomical site documented.