CLM-2026-006165
Desert Internal Medicine Associates, Internal Medicine. Service 2026-06-05 at office (POS 11). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Gabriel Hayes
- Member ID
- UHC-38572-50
- Date of birth
- 1988-05-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416187
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2100
- Coverage period
- 2025-03-01 to present
- Deductible
- $616.14 of $1,000.0062%
- Out-of-pocket maximum
- $56.15 of $4,000.001%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3013140306
- Network
- In network
- Rendering NPI
- 3549284834
- Location
- Tempe, AZ · TIN 35-1948033
- 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 | $330.00 | $204.60 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $218.00 | $135.16 | — | — | Review |
| Totals | $548.00 | $339.76 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-913715
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037823 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-05: NULL (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 34 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 (3013140306). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications rec”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Internal Medicine Associates2026-06-05 09:12
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-09 02:17
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-09 14:29
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.