CLM-2026-006808
Desert Internal Medicine Associates, Internal Medicine. Service 2025-10-15 at office (POS 11). Received 2026-04-28.
Member
Resolved through the identity graph
- Member
- Julie Fernandez
- Member ID
- UHC-84577-80
- Date of birth
- 1978-03-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402295
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3571
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,092.73 of $1,500.0073%
- Out-of-pocket maximum
- $1,038.27 of $4,500.0023%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 2685645824
- Location
- Houston, TX · TIN 11-1256116
- 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 | $314.00 | $194.68 | — | — | DeniedN30 |
| Totals | $314.00 | $194.68 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-697315
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028161 (verified, link confidence 0.99). | |
| Eligibility | Fail | N30 | Date of service 2025-10-15 is before coverage effective date 2025-12-01. Patient ineligible for this service |
| Timely filing | Fail | CO29 | Received 195 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 Desert Internal Medicine Associates (5106489862). | |
| 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: Desert Internal Medicine Associates2025-10-15 13:35
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-28 02:06
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2025-10-15 is before coverage effective date 2025-12-01. Timely filing: Received 195 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024192 | 2026-05-23 | Lakeside Reference Lab | $206.00 | Approved |
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.