CLM-2026-003566
Valley Internal Medicine Associates, Internal Medicine. Service 2026-06-26 at office (POS 11). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Mark Gomez
- Member ID
- UHC-29262-82
- Date of birth
- 1962-09-20
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-401178
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7904
- Coverage period
- 2025-06-01 to present
- Deductible
- $36.62 of $1,500.002%
- Out-of-pocket maximum
- $2,089.86 of $4,500.0046%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5095030487
- Network
- In network
- Rendering NPI
- 5359532665
- Location
- Charlotte, NC · TIN 47-3292895
- 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 | $420.00 | $260.40 | — | — | DeniedCO29 |
| Totals | $420.00 | $260.40 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-968188
- 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-043828 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-26: MEDICARE-ADV-A (MA), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 108 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Internal Medicine Associates (5095030487). | |
| 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: Valley Internal Medicine Associates2026-06-26 18:02
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-12 06:30
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-12 16:28
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 108 days after the last date of service (limit 90).
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
Received after the timely-filing limit.