CLM-2026-002099
Desert Diabetes Center, Endocrinology. Service 2026-02-17 at office (POS 11). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Sarah Crawford
- Member ID
- UHC-50173-29
- Date of birth
- 1969-04-22
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-410185
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7526
- Coverage period
- 2023-06-01 to present
- Deductible
- $395.20 of $1,000.0040%
- Out-of-pocket maximum
- $309.04 of $2,000.0015%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 9036243431
- Location
- Phoenix, AZ · TIN 51-1868485
- 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 | $374.00 | $231.88 | — | — | Review |
| Totals | $374.00 | $231.88 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-598078
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-023665 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-17: SELECT-EPO (EPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 52 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-002098, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Diabetes Center (4143565768). | |
| 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 Diabetes Center2026-02-17 18:13
Established patient presents with hypothyroidism, unspecified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-10 04:23
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-10 10:52
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-002098, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002098 | 2026-02-17 | Mesa Diabetes Center | $374.00 | 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
Different billing provider; separately payable.