CLM-2026-006867
Desert Internal Medicine Associates, Internal Medicine. Service 2026-01-10 to 2026-01-14 at inpatient hospital (POS 21). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Douglas Padilla
- Member ID
- UHC-70673-95
- Date of birth
- 1983-05-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421310
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8061
- Coverage period
- 2025-04-01 to present
- Deductible
- $2,142.85 of $2,500.0086%
- Out-of-pocket maximum
- $1,491.48 of $10,000.0015%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9861363924
- Network
- In network
- Rendering NPI
- 1432108268
- Location
- Tampa, FL · TIN 69-3872191
- 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 | $202.00 | $111.10 | $111.10 | $0.00 | Paid |
| Totals | $202.00 | $111.10 | $111.10 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-200506
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-10 to 2026-01-14
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005692 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-10: N/A (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 5 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 (9861363924). | |
| 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 Associates2026-01-14 10:58
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-200506.pdf2 pages
Itemised statement totalling $202.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.