CLM-2026-006407
Desert Medical Group, Internal Medicine. Service 2026-05-04 to 2026-05-08 at inpatient hospital (POS 21). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Frank Garcia
- Member ID
- UHC-99822-51
- Date of birth
- 1940-07-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426907
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0844
- Coverage period
- 2025-11-01 to 2026-08-06
- Deductible
- $2,237.66 of $2,500.0090%
- Out-of-pocket maximum
- $178.01 of $5,000.004%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5303428622
- Network
- In network
- Rendering NPI
- 2894073628
- Location
- Atlanta, GA · TIN 67-2719316
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $205.00 | $112.75 | — | — | Review |
| Totals | $205.00 | $112.75 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-536428
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-04 to 2026-05-07
- 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-029779 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-04: CHOICE-PLUS-PPO (PPO), effective 2025-11-01, terms 2026-08-06. | |
| Timely filing | Pass | Received 0 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 (5303428622). | |
| 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 chronic kidney disease, stage 3 unspecified. 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
- SystemSystem: Claims system2026-05-08 04:29
Rendering provider signature missing on the attached note. Development letter sent to provider.
- ClinicalProvider: Desert Medical Group2026-05-08 11:12
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
Attachments
Documents received with the claim
- Itemized billitemized_PA-536428.pdf4 pages
Itemised statement totalling $205.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005239 | 2026-06-05 | Meadow GI Associates | $1,977.00 | Approved |
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.