CLM-2026-000875
Desert Internal Medicine Associates, Internal Medicine. Service 2025-12-14 to 2025-12-17 at inpatient hospital (POS 21). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Isabella Mendoza
- Member ID
- UHC-26500-93
- Date of birth
- 1952-11-27
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-426895
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0283
- Coverage period
- 2025-03-01 to present
- Deductible
- $223.59 of $500.0045%
- Out-of-pocket maximum
- $458.06 of $1,500.0031%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9861363924
- Network
- In network
- Rendering NPI
- 9032228634
- Location
- Tampa, FL · TIN 69-3872191
- Authorisation / referral
- none / none
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 | $201.00 | $110.55 | $110.55 | $0.00 | Paid |
| Totals | $201.00 | $110.55 | $110.55 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-144918
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-14 to 2025-12-15
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000872 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-14: N/A (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 17 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 (9861363924). | |
| 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 Associates2025-12-17 17:03
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-144918.pdf8 pages
Itemised statement totalling $201.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.