CLM-2026-006683
Unity Medical Group, Internal Medicine. Service 2026-06-05 to 2026-06-08 at inpatient hospital (POS 21). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Kathleen Cruz
- Member ID
- UHC-59287-85
- Date of birth
- 1967-10-10
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-404350
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0933
- Coverage period
- 2024-10-01 to present
- Deductible
- $742.81 of $1,500.0050%
- Out-of-pocket maximum
- $619.93 of $3,000.0021%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 7889412954
- Location
- Mesa, AZ · TIN 43-9161942
- 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 | $258.00 | $141.90 | $141.90 | $0.00 | Paid |
| Totals | $258.00 | $141.90 | $141.90 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-662380
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-05 to 2026-06-09
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013631 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-05: MEDICARE-ADV-B (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 42 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 Unity Medical Group (1355996814). | |
| 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 Medical Group2026-06-08 16:34
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-662380.pdf4 pages
Itemised statement totalling $258.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005694 | 2026-06-29 | Northgate Orthopedic Specialists | $29,657.00 | Needs review |
| CLM-2026-005693 | 2026-06-29 | Valley Bone and Joint Center | $29,657.00 | Needs review |
| CLM-2026-018004 | 2026-01-26 | Lakeside Skin Care Associates | $977.00 | 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.