CLM-2026-010561
Unity Internal Medicine Associates, Internal Medicine. Service 2026-08-24 to 2026-08-26 at inpatient hospital (POS 21). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Michael Stone
- Member ID
- UHC-84625-12
- Date of birth
- 1974-01-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402304
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8147
- Coverage period
- 2021-09-01 to present
- Deductible
- $303.74 of $1,500.0020%
- Out-of-pocket maximum
- $968.96 of $3,000.0032%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 7180251952
- Location
- Atlanta, GA · TIN 10-7193981
- 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 | $188.00 | $84.60 | $84.60 | $0.00 | Paid |
| Totals | $188.00 | $84.60 | $84.60 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-594352
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-24 to 2026-08-28
- 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-020792 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-24: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 24 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-08-26 09:20
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-594352.pdf8 pages
Itemised statement totalling $188.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.