CLM-2026-007656
Desert Diabetes Center, Endocrinology. Service 2026-06-11 at office (POS 11). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Dylan Foster
- Member ID
- UHC-84539-43
- Date of birth
- 1970-07-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409971
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1877
- Coverage period
- 2023-05-01 to 2026-04-15
- Deductible
- $1,478.54 of $3,500.0042%
- Out-of-pocket maximum
- $2,611.00 of $14,000.0019%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 1398309793
- Location
- Phoenix, AZ · TIN 51-1868485
- Authorisation / referral
- none / REF674527
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 | $328.00 | $203.36 | — | — | DeniedCO27 |
| Totals | $328.00 | $203.36 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-804229
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018096 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-04-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 Diabetes Center (4143565768). | |
| 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 Diabetes Center2026-06-11 16:52
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-07-22 00:47
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-22 14:26
Called the provider office; awaiting documentation.
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 2026-06-11 is after coverage terminated on 2026-04-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017615 | 2026-04-14 | Pinecrest Medical Group | $519.00 | 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
Service after coverage termination.