CLM-2026-000084
Desert Internal Medicine Associates, Internal Medicine. Service 2026-04-12 at office (POS 11). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Noah Carroll
- Member ID
- UHC-13848-99
- Date of birth
- 1986-11-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408745
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1610
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,865.56 of $2,500.0075%
- Out-of-pocket maximum
- $516.66 of $5,000.0010%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 1312177144
- Location
- Mesa, AZ · TIN 70-7613029
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $76.00 | $47.12 | $20.00 | $27.12 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $302.00 | $187.24 | $0.00 | $187.24 | Paid |
| Totals | $378.00 | $234.36 | $20.00 | $214.36 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-456759
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026528 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-12: N/A (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 6 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 Internal Medicine Associates (6778439607). | |
| 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 Internal Medicine Associates2026-04-12 17:20
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024253 | 2026-09-01 | Heritage Rehabilitation Center | $180.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.