CLM-2026-002018
Unity Medical Group, Internal Medicine. Service 2026-01-13 at office (POS 11). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Danielle Torres
- Member ID
- UHC-36695-30
- Date of birth
- 2003-09-16
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-409720
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2487
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,095.51 of $2,500.0084%
- Out-of-pocket maximum
- $4,894.95 of $10,000.0049%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 1246803518
- Location
- Mesa, AZ · TIN 43-9161942
- 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 | $79.00 | $48.98 | $30.00 | $18.98 | Paid |
| Totals | $79.00 | $48.98 | $30.00 | $18.98 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-827624
- 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-004748 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-13: NULL (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 20 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 | 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 Group2026-01-13 16:23
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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-2026-023468 | 2025-12-03 | Canyon Medical Group | $79.00 | 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.