CLM-2026-001098
Unity Medical Group, Internal Medicine. Service 2025-11-22 at office (POS 11). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Marilyn Guerrero
- Member ID
- UHC-39266-24
- Date of birth
- 1961-03-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420874
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group N/A
- Coverage period
- 2022-02-01 to present
- Deductible
- $2,059.89 of $3,500.0059%
- Out-of-pocket maximum
- $4,238.76 of $14,000.0030%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1276733437
- Network
- In network
- Rendering NPI
- 8162296197
- Location
- Dallas, TX · TIN 20-2485956
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $291.00 | $180.42 | — | — | DeniedCO29 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $87.00 | $53.94 | — | — | DeniedCO29 |
| Totals | $378.00 | $234.36 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-687774
- 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-034968 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-22: MEDICARE-ADV-B (MA), effective 2022-02-01. | |
| Timely filing | Fail | CO29 | Received 205 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (1276733437). | |
| 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: Unity Medical Group2025-11-22 10:25
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-15 06:38
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 205 days after the last date of service (limit 90).
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
Received after the timely-filing limit.