CLM-2026-004736
Unity Internal Medicine Associates, Internal Medicine. Service 2026-05-11 at office (POS 11). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- James Day
- Member ID
- UHC-69120-92
- Date of birth
- 1956-11-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405601
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6322
- Coverage period
- 2025-07-01 to present
- Deductible
- $781.96 of $1,000.0078%
- Out-of-pocket maximum
- $1,025.07 of $4,000.0026%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 7477849963
- Location
- Atlanta, GA · TIN 10-7193981
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $289.00 | $130.05 | $40.00 | $90.05 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $288.00 | $129.60 | $0.00 | $129.60 | Paid |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $77.00 | $34.65 | $0.00 | $34.65 | Paid |
| Totals | $654.00 | $294.30 | $40.00 | $254.30 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-310427
- 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-031723 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-11: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 10 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Internal Medicine Associates2026-05-11 12:02
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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034380 | 2026-05-08 | Desert Internal Medicine Associates | $210.00 | 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.