CLM-2026-001272
Unity Internal Medicine Associates, Internal Medicine. Service 2026-05-04 at office (POS 11). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Doris Yang
- Member ID
- UHC-09369-79
- Date of birth
- 1968-12-03
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-411058
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0195
- Coverage period
- 2025-08-01 to 2026-01-24
- Deductible
- $2,124.64 of $2,500.0085%
- Out-of-pocket maximum
- $1,821.50 of $5,000.0036%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 2082330319
- Location
- Atlanta, GA · TIN 10-7193981
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $241.00 | $108.45 | — | — | DeniedCO27 |
| Totals | $241.00 | $108.45 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-676778
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017819 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-04 is after coverage terminated on 2026-01-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Internal Medicine Associates2026-05-04 09:17
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-31 06:46
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-31 10:45
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-04 is after coverage terminated on 2026-01-24. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028519 | 2026-09-05 | Pinecrest Diagnostic Imaging | $721.00 | Denied |
| CLM-2026-025519 | 2026-04-14 | Harbor Regional Medical Center | $3,715.00 | Denied |
| CLM-2026-023065 | 2026-04-13 | Meadow Reference Lab | $40.00 | Denied |
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
Service after coverage termination.