CLM-2026-009870
Unity Internal Medicine Associates, Internal Medicine. Service 2026-01-07 at office (POS 11). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Catherne Nelson
- Member ID
- UHC-61771-81
- Date of birth
- 1954-10-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402515
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6358
- Coverage period
- 2023-11-01 to present
- Deductible
- $307.32 of $500.0061%
- Out-of-pocket maximum
- $61.79 of $1,000.006%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 5449201644
- Location
- Atlanta, GA · TIN 10-7193981
- Authorisation / referral
- none / REF874600
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 | $295.00 | $132.75 | — | — | DeniedCO204 |
| Totals | $295.00 | $132.75 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-186619
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003014 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-07: CORE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Pass | Received 3 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 | Fail | CO204 | Billing provider 8984483692 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Internal Medicine Associates2026-01-07 17:04
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-10 03:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8984483692 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.