CLM-2026-002810
Desert Medical Group, Internal Medicine. Service 2026-07-27 at office (POS 11). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Amy Daniels
- Member ID
- UHC-31366-36
- Date of birth
- 2007-04-08
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-406638
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2637
- Coverage period
- 2025-04-01 to 2026-03-16
- Deductible
- $337.36 of $3,500.0010%
- Out-of-pocket maximum
- $1,905.32 of $14,000.0014%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 5418103292
- Location
- Scottsdale, AZ · TIN 56-2756422
- 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 | $67.00 | $41.54 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $262.00 | $162.44 | — | — | DeniedCO27 |
| Totals | $329.00 | $203.98 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-974670
- 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-029786 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-27 is after coverage terminated on 2026-03-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 25 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 Medical Group (4556045621). | |
| 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 Medical Group2026-07-27 17:20
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-08-21 06:04
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-21 08:07
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-27 is after coverage terminated on 2026-03-16.
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
Service after coverage termination.