CLM-2026-002247
Desert Internal Medicine Associates, Internal Medicine. Service 2026-08-15 at office (POS 11). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Camila Jensen
- Member ID
- UHC-66295-51
- Date of birth
- 1949-11-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419515
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2498
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,063.82 of $2,500.0043%
- Out-of-pocket maximum
- $130.71 of $7,500.002%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 4077633319
- Location
- Houston, TX · TIN 11-1256116
- Authorisation / referral
- none / REF281407
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 | $269.00 | $166.78 | $40.00 | $126.78 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $41.00 | $25.42 | $0.00 | $25.42 | Paid |
| Totals | $310.00 | $192.20 | $40.00 | $152.20 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-124614
- 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-027078 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-15: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 16 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 (5106489862). | |
| 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 Associates2026-08-15 09:08
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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-2026-013189 | 2026-08-27 | Canyon Reference Lab | $171.00 | Denied |
| CLM-2026-023946 | 2026-05-09 | Evergreen Reference Lab | $40.00 | 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.