CLM-2026-007145
Unity Medical Group, Internal Medicine. Service 2026-04-29 at office (POS 11). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Carolyn Berry
- Member ID
- UHC-09486-83
- Date of birth
- 1961-03-20
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-409563
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8295
- Coverage period
- 2022-06-01 to present
- Deductible
- $112.01 of $2,500.004%
- Out-of-pocket maximum
- $3,270.38 of $7,500.0044%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 8868576819
- Location
- Mesa, AZ · TIN 43-9161942
- Authorisation / referral
- none / REF404124
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $279.00 | $172.98 | $20.00 | $152.98 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $282.00 | $174.84 | $0.00 | $174.84 | Paid |
| Totals | $561.00 | $347.82 | $20.00 | $327.82 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-617345
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-025821 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-29: NAVIGATE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 28 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 Group2026-04-29 10:03
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011942 | 2026-05-04 | Unity Primary Care Associates | $697.00 | Denied |
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.