CLM-2026-000804
Unity Medical Group, Internal Medicine. Service 2025-12-09 to 2025-12-13 at inpatient hospital (POS 21). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Ralph Graham
- Member ID
- UHC-10242-73
- Date of birth
- 1981-01-27
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408379
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8922
- Coverage period
- 2022-03-01 to present
- Deductible
- $199.34 of $3,500.006%
- Out-of-pocket maximum
- $307.07 of $7,000.004%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 8922283238
- Location
- Mesa, AZ · TIN 43-9161942
- Authorisation / referral
- none / REF990234
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $260.00 | $143.00 | — | — | Review |
| Totals | $260.00 | $143.00 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-953574
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-09 to 2025-12-12
- 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-000817 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-09: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 33 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 Unity Medical Group (1355996814). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Medical Group2025-12-13 15:01
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-15 00:52
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-15 14:45
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-953574.pdf5 pages
Itemised statement totalling $260.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017938 | 2026-08-10 | Canyon Cardiovascular Associates | $278.00 | Denied |
| CLM-2026-024655 | 2025-11-20 | Evergreen Clinical Laboratories | $92.00 | Approved |
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
Development letter outstanding.