CLM-2026-011208
Unity Internal Medicine Associates, Internal Medicine. Service 2026-03-27 at office (POS 11). Received 2026-04-25.
Member
Resolved through the identity graph
- Member
- Wei Gardner
- Member ID
- UHC-94736-96
- Date of birth
- 1971-04-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404450
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7448
- Coverage period
- 2025-11-01 to 2026-02-22
- Deductible
- $15.87 of $1,500.001%
- Out-of-pocket maximum
- $990.44 of $4,500.0022%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 5337493691
- Location
- Atlanta, GA · TIN 10-7193981
- Authorisation / referral
- none / REF485186
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 | $280.00 | $126.00 | — | — | DeniedCO27 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $90.00 | $40.50 | — | — | DeniedCO27 |
| Totals | $370.00 | $166.50 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-869425
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006490 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-27 is after coverage terminated on 2026-02-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 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 Associates2026-03-27 13:42
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-25 00:48
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-25 15:04
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-27 is after coverage terminated on 2026-02-22. Provider 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
Service after coverage termination.